Business strategy and healthcare

Category Archives: Democrats

As the idiots in Congress still fight over the wall and continue to act like spoiled children we, the intelligent voters should be looking at healthcare delivery reality. What can we expect from these liberals and their cultural revolution? Joyce Frieden, the News Editor of MedPage Today pointed out last year that a reckoning is coming to American healthcare, said Chester Burrell, outgoing CEO of the CareFirst BlueCross BlueShield health plan, here at the annual meeting of the National Hispanic Medical Association.

Burrell, speaking on Friday, told the audience there are five things physicians should worry about, “because they worry me”:

The effects of the recently passed tax bill.“If the full effect of this tax cut is experienced, then the federal debt will go above 100% of GDP [gross domestic product] and will become the highest it’s been since World War II,” said Burrell. That may be OK while the economy is strong, “but we’ve got a huge problem if it ever turns and goes back into recession mode,” he said. “This will stimulate higher interest rates, and higher interest rates will crowd out funding in the federal government for initiatives that are needed,” including those in healthcare.

Burrell noted that Medicaid, 60 million by Medicare, currently covers 74 million people and 10 million by the Children’s Health Insurance Program (CHIP), while another 10 million people are getting federally subsidized health insurance through the Affordable Care Act’s (ACA’s) insurance exchanges. “What happens when interest’s demand on federal revenue starts to crowd out future investment in these government programs that provide healthcare for tens of millions of Americans?”

The increasing obesity problem.”Thirty percent of the U.S. population is obese; 70% of the total population is either obese or overweight,” said Burrell. “There is an epidemic of diabetes, heart disease, and coronary artery disease coming from those demographics, and Baby Boomers will see these things in full flower in the next 10 years as they move fully into Medicare.”

The “congealing” of the U.S. healthcare system. This is occurring in two ways, Burrell said. First, “you’ll see large integrated delivery systems [being] built around academic medical centers — very good quality care [but] 50%-100% more expensive than the community average.”

To see how this affects patients, take a family of four — a 40-year-old dad, 33-year-old mom, and two teenage kids — who are buying a health insurance policy from CareFirst via the ACA exchange, with no subsidy. “The cost for their premium and deductibles, copays, and coinsurance [would be] $33,000,” he said. But if all of the care were provided by academic medical centers? “$60,000,” he said. “What these big systems are doing is consolidating community hospitals and independent physician groups, and creating oligopolies.”

Another way the system is “congealing” is the emergence of specialty practices that are backed by private equity companies, said Burrell. “The largest urology group in our area was bought by a private equity firm. How do they make money? They increase fees. There is not an issue of quality but there is a profound issue on costs.”

The undermining of the private healthcare market. “Just recently, we have gotten rid of the individual mandate, and the [cost-sharing reduction] subsidies that were [expected to be] in the omnibus bill … were taken out of the bill,” he said. And state governments are now developing alternatives to the ACA such as short-term duration insurance policies — originally designed to last only 3 months but now being pushed up to a year, with the possibility of renewal — that don’t have to adhere to ACA coverage requirements, said Burrell.

The lackluster performance of new payment models.”Despite the innovation fostering under [Center for Medicare & Medicaid Innovation] programs — the whole idea was to create a series of initiatives that might show the wave of the future — ACOs [accountable care organizations] and the like don’t show the promise intended for them, and there is no new model one could say is demonstrably more successful,” he said.

“So beware — there’s a reckoning coming,” Burrell said. “Maybe change occurs only when there is a rip-roaring crisis; we’re coming to it.” Part of the issue is cost: “As carbon dioxide is to global warming, the cost is to healthcare. We deal with it every day … We face a future where cutbacks in funding could dramatically affect the accessibility of care.”

“Does that mean we move to move single-payer, some major repositioning?” he said. “I don’t know, but in 35 years in this field, I’ve never experienced a time quite like this … Be vigilant, be involved, be committed to serving these populations.”

VA Seeks to Redirect Billions of Dollars into Private Care

Jennifer Steinhauer and Dave Phillipps reported that The Department of Veterans Affairs is preparing to shift billions of dollars from government-run veterans’ hospitals to private health care providers, setting the stage for the biggest transformation of the veterans’ medical system in a generation.

Under proposed guidelines, it would be easier for veterans to receive care in privately run hospitals and have the government pay for it. Veterans would also be allowed access to a system of proposed walk-in clinics, which would serve as a bridge between V.A. emergency rooms and private providers, and would require co-pays for treatment.

Veterans’ hospitals, which treat seven million patients annually, have struggled to see patients on time in recent years, hit by a double crush of returning Iraq and Afghanistan veterans and aging Vietnam veterans. A scandal over hidden waiting lists in 2014 sent Congress searching for fixes, and in the years since, Republicans have pushed to send veterans to the private sector, while Democrats have favored increasing the number of doctors in the V.A.

If put into effect, the proposed rules — many of whose details remain unclear as they are negotiated within the Trump administration — would be a win for the once-obscure Concerned Veterans for America, an advocacy group funded by the network founded by the billionaire industrialists Charles G. and David H. Koch, which has long championed increasing the use of private sector health care for veterans.

For individual veterans, private care could mean shorter waits, more choices and fewer requirements for co-pays — and could prove popular. But some health care experts and veterans’ groups say the change, which has no separate source of funding, would redirect money that the current veterans’ health care system — the largest in the nation — uses to provide specialty care.

Critics have also warned that switching vast numbers of veterans to private hospitals would strain care in the private sector and that costs for taxpayers could skyrocket. In addition, they say it could threaten the future of traditional veterans’ hospitals, some of which are already under review for consolidation or closing.

President Trump, who made reforming veterans’ health care a major point of his campaign, may reveal details of the plan in his State of the Union address later this month, according to several people in the administration and others outside it who have been briefed on the plan.

The proposed changes have grown out of health care legislation, known as the Mission Act, passed by the last Congress. Supporters, who have been influential in administration policy, argue that the new rules would streamline care available to veterans, whose health problems are many but whose numbers are shrinking, and also prod the veterans’ hospital system to compete for patients, making it more efficient.

“Most veterans chose to serve their country, so they should have the choice to access care in the community with their V.A. benefits — especially if the V.A. can’t serve them in a timely and convenient manner,” said Dan Caldwell, executive director of Concerned Veterans for America.

In remarks at a joint hearing with members of the House and Senate veterans’ committees in December, Mr. Wilkie said veterans largely liked using the department’s hospitals.

“My experience is veterans are happy with the service they get at the Department of Veterans Affairs,” he said. Veterans are not “chomping at the bit” to get services elsewhere, he said, adding, “They want to go to places where people speak the language and understand the culture.”

Health care experts say that whatever the larger effects, allowing more access to private care will prove costly. A 2016 report ordered by Congress, from a panel called the Commission on Care, analyzed the cost of sending more veterans into the community for treatment and warned that unfettered access could cost well over $100 billion each year.

A fight over the future of the veterans’ health care system played a role in the ousting of the department’s previous secretary, David J. Shulkin, center.

Tricare costs have climbed steadily, and the Tricare population is younger and healthier than the general population, while Veterans Affairs patients are generally older and sicker.

Though the rules would place some restrictions on veterans, early estimates by the Office of Management and Budget found that a Tricare-style system would cost about $60 billion each year, according to a former Veterans Affairs official who worked on the project. Congress is unlikely to approve more funding, so the costs are likely to be carved out of existing funds for veterans’ hospitals.

At the same time, Tricare has been popular among recipients — so popular that the percentage of military families using it has nearly doubled since 2001, as private insurance became more expensive, according to the Harvard lecturer Linda Bilmes.

“People will naturally gravitate toward the better deal, that’s economics,” she said. “It has meant a tremendous increase in costs for the government.”

A spokesman for the Department of Veterans Affairs, Curt Cashour, declined to comment on the specifics of the new rules.

“The Mission Act, which sailed through Congress with overwhelming bipartisan support and the strong backing of veterans service organizations, gives the V.A. secretary the authority to set access standards that provide veterans the best and most timely care possible, whether at V.A. or with community providers, and the department is committed to doing just that,” he said in an email.

Dr. Shulkin, the former secretary, shared that concern. Though he said he supported increasing the use of private health care, he favored a system that would let department doctors decide when patients were sent outside for private care.

The cost of the new rules, he said, could be higher than expected, because most veterans use a mix of private insurance, Medicare and veterans’ benefits, choosing to use the benefits that offer the best deal. Many may choose to forgo Medicare, which requires a substantial co-pay if Veterans Affairs offers private care at no charge. And if enough veterans leave the veterans’ system, he said, it could collapse.

Robert L. Wilkie, the secretary of veterans’ affairs, has repeatedly said his goal is not to privatize veterans’ health care.

One of the group’s former senior advisers, Darin Selnick, played a key role in drafting the Mission Act as a veterans’ affairs adviser at the White House’s Domestic Policy Council and is now a senior adviser to the secretary of Veterans Affairs in charge of drafting the new rules. Mr. Selnick clashed with David J. Shulkin, who was the head of the V.A. for a year under Mr. Trump and is widely viewed as being instrumental in ending Mr. Shulkin’s tenure.

Mr. Selnick declined to comment.

Critics, which include nearly all of the major veterans’ organizations, say that paying for care in the private sector would starve the 153-year-old veterans’ health care system, causing many hospitals to close.

“We don’t like it,” said Rick Weidman, executive director of Vietnam Veterans of America. “This thing was initially sold as to supplement the V.A., and some people want to try and use it to supplant.”

Members of Congress from both parties have been critical of the administration’s inconsistency and lack of details in briefings. At a hearing last month, Senator John Boozman, Republican of Arkansas, told Robert L. Wilkie, the current secretary of Veterans Affairs, that his staff had sometimes come to Capitol Hill “without their act together.”

Although the Trump administration has kept details quiet, officials inside and outside the department say the plan closely resembles the military’s insurance plan, Tricare Prime, which sets a lower bar than the Department of Veterans Affairs when it comes to getting private care.

Tricare automatically allows patients to see a private doctor if they have to travel more than 30 minutes for an appointment with a military doctor, or if they have to wait more than seven days for a routine visit or 24 hours for urgent care. Under current law, veterans qualify for private care only if they have waited 30 days, and sometimes they have to travel hundreds of miles. The administration may propose for veterans a time frame somewhere between the seven- and 30-day periods.

Mr. Wilkie has repeatedly said his goal is not to privatize veterans’ health care, but would not provide details of his proposal when asked at a hearing before Congress in December.

Access to VA Health Services Now Better Than Private Hospitals?

So, the question is with the shift of funding to the privatization of VA care is access better? Nicole Lou, contributing writer for the MedPage noted that efforts to stir up access to Veterans Affairs (VA) hospitals have cut down on wait times for new patient appointments, according to a report.

In 2014, the average wait for a new VA appointment in primary care, dermatology, cardiology, or orthopedics was 22.5 days, compared with 18.7 days in private sector facilities (P=0.20). Although these wait times were statistically no different in general, there was a longer wait for an orthopedics appointment in the VA that year (23.9 days vs 9.9 days for private sector, P<0.001), noted David Shulkin, MD, former VA secretary under President Trump, and now at the University of Pennsylvania’s Leonard Davis Institute of Health Economics, and colleagues.

The study, published in JAMA Network Open, found that wait times in 2017 favored VA medical centers (17.7 days vs 29.8 days for private sector facilities, P<0.001). This was observed for primary care, dermatology, and cardiology appointments — but not orthopedics, which continued to produce appointment lags in the VA system (20.9 days vs 12.4 days, P=0.01), the authors stated.

“Although the results reflect positively on the VA, we intend to continue improving wait times, the accuracy of the data captured, and the transparency of reporting information to veterans and the public,” the researchers wrote.

Their study included VA medical centers in 15 major metropolitan areas and compared them with private sector facilities. Wait times were calculated differently based on VA records and secret shopper surveys, respectively, which was a limitation of the study, the team said.

Shulkin and colleagues found that VA wait times trended toward improvement in 11 of 15 regions, whereas private medical centers had significant increases in wait times in 12 of the 15.

Prompting the scrutiny over VA hospital wait times was a 2014 report showing that at least 40 veterans died waiting for appointments at the Phoenix VA Health Care System in Arizona. Even worse, the wait times had apparently been deliberately manipulated to look better than they were.

“This incident damaged the VA’s credibility and created a public perception regarding the VA health care system’s inability to see patients in a timely manner,” Shulkin and co-authors said. “In response, the VA has worked to improve access, including primary care, mental health, and other specialty care services.”

Meanwhile, VA medical centers continue to suffer from staffing issues such as high turnover and employee vacancies in the tens of thousands.

The study authors noted a modest increase in the number of patients going to VA hospitals for the four services studied, although that number still stayed around five million per year.

Another problem with the methodology of the study was that it failed to address how easily established patients could obtain return appointments, noted an accompanying editorial by Peter Kaboli, MD, MS, of Iowa City Veterans Affairs Healthcare System, and Stephan Fihn, MD, MPH, of the University of Washington in Seattle and JAMA Network Open’s deputy editor.

Furthermore, they pointed out, a patient returning for a 6-month follow-up visit may show up in the scheduling system as having a long delay.

“As this study highlights, measuring access to healthcare remains dodgy. Even so, the seven million veterans who receive care from the VA seem able to obtain routine and urgent care in a time frame that is on par for other Americans despite increasing demand, although there are and always will be exceptions,” Kaboli and Fihn noted.

“As resources in the VA are increasingly diverted to purchase care in the community, it remains to be seen if access to healthcare services can be maintained while access in the private sector continues to deteriorate,” they continued, adding that virtual care may be one way to improve access given the non-infinite supply of face-to-face appointments.

The VA experience seems to say that privatization of healthcare delivery is the way to go with improved access to care. So, onward to discuss universal healthcare and single payer systems of health care delivery. What would they all look like and what are the strategies to develop any of these systems.

And we continue with the shut down of 25% of the government. Maybe it isn’t such a bad deal for us with the waste and deficit. So, what can we anticipate for the New Year regarding healthcare? Miss Luthi reviewed that year one of a divided government in the Trump era begins with the Affordable Care Act again in legal peril. Political rhetoric around the law and healthcare generally will only intensify in the lead-up to the 2020 election cycle, but the industry is most closely watching how the administration will use executive authority to try to beat down soaring costs.

A Texas judge’s decision to overturn the ACA closed out a year where, despite congressional gridlock on healthcare, the Trump administration gained ground on systemic attempts to trim hospital payments and pharmaceutical prices, as well as reshape insurance markets. HHS Secretary Alex Azar maintains he will not bend to corporate pressure as he pushes policies like site-neutral payments and price transparency.

The policy outlook is less straightforward in Congress, where Democrats plan to use their newfound power in the House to blanket the Trump administration with oversight.

Meanwhile, Sens. Chuck Grassley (R-Iowa) and Lamar Alexander (R-Tenn.) will wrap up their legacies chairing the upper chamber’s two most influential healthcare committees—Finance and Health, Education, Labor, and Pensions, respectively. Grassley has a history of scrutinizing tax-exempt providers. And Alexander orchestrated a series of hearings in 2017 delving into the high cost of healthcare.

HHS and hospitals: It’s complicated

Hospitals want the Trump administration to more aggressively pushing executive authority to roll back red tape, particularly around the Stark law and accompanying regulations, which providers say stand in the way of some pay-for-value reforms, including building clinically integrated networks.

But hospitals have also been quick to sue over what they claim is an executive overreach, such as in the case of HHS’ sweeping cuts to the controversial 340B drug discount program. Pharmaceutical discounts through the program yield tens of millions of dollars annually for a growing number of hospitals, and it has become a territorial fight.

“This administration pushes the envelope on how far they can go with powers from Congress,” said Erik Rasmussen, a vice president at the American Hospital Association. “It’s a double-edged sword. When they go too far, we sue them.”

Hospitals sued over the government’s substantial clawback of money through a cut to 340B hospitals’ Medicare Part B drug reimbursements. Launched Jan. 1 of last year, the policy is winding its way through courts under ongoing litigation after a late-breaking 2018 win for hospitals in a federal district court. The cuts were extended to hospitals’ off-campus facilities at the beginning of this year.

Hospitals also poured lobbying dollars last year into a fight against Republican-sponsored legislation to cut back the 340B program. With a Democratic takeover of the House, hospitals are expecting a break on Capitol Hill and they plan to use the time to try to forestall political pressures over the program. Hospitals will have to disclose the community benefit funded by their 340B discount money from manufacturers, accurately estimate their discounts, and pledge to stick to the letter of the 340B law.

“We want to use the time while the field is fallow to make sure our fences are strong,” Rasmussen said. “Good fences make good neighbors.”

Hospitals and HHS anticipate a ruling on the so-called site-neutral payment policy, proposed in July and finalized in a watered-down version in November. The AHA, along with several other hospital groups, sued over the policy, again claiming executive overreach.

This administration pushes the envelope on how far they can go with powers from Congress. It’s a double-edged sword. When they go too far, we sue them.”

Under the new policy that starts this month, Medicare will pay off-site clinics the same rate it pays independent physicians for certain services.

Economist Douglas Holtz-Eakin, a former director of the Congressional Budget Office who heads the conservative American Action Forum, said it is unclear how hard the administration will ultimately come down on hospitals in light of the intense pressure.

“It has turned out to be harder than the administration expected,” Holtz-Eakin said of the payment policy. “They keep going back and forth on a policy to pay for the quality of the service, rather than paying the same rate for every site, and they’re just struggling.”

While the administration would like to keep balancing Medicare payments, he added, officials “don’t know where to go next” as they try to work out designs for these policy changes.

Hospital priorities for Congress: DSH payments

Congress has a hard deadline of Sept. 30 to decide how to manage the scheduled disproportionate-share hospital payment cuts, passed with the ACA, but never implemented.

Lawmakers last year authorized a one-year-only delay to billions of dollars in cuts to these payments, teeing up a potential legislative overhaul of the program in 2019. Republican Sen. Marco Rubio of Florida, one of the states least favored under the current formulas, has already introduced a proposal to start negotiations.

Hospital lobbyists, eager to protect overall DSH funding, have signaled lawmakers could modify the law, which has largely remained untouched since 1992.

“The devil’s in the details,” said Carlos Jackson of America’s Essential Hospitals—a trade group for hospitals that benefit significantly from the program. “We are happy to have conversations about changes, but the details matter.”

Jackson also questioned whether lawmakers in this supercharged political environment would be able to dive into real policy changes by September.

“Will they have the time?” he asked.

A small number of states—Alabama, Missouri, New Jersey, and New York—benefit more than others from DSH. Financially, the payments are a very big deal for hospitals with high numbers of Medicaid patients, such as major university medical centers.

Here, too, ongoing litigation is a complicating factor. Hospitals have challenged an Obama-era rule requiring them to deduct any Medicare or commercial insurance reimbursements from their total DSH allotment.

Hospitals also want the Democratic House to pick up where Republicans left off on a “Red Tape Relief” project targeting Medicare regulations that hospitals say cost them billions a year in extra work and unnecessary or redundant expenses.

Democrats haven’t decided what they will do, but lobbyists think House Republicans may be able to work with the Trump administration on policy work that could gain bipartisan support.

“It’s been a while since we’ve had a GOP minority in the House with a Republican president,” the AHA’s Rasmussen said. “Republicans in the House will still be important because they can work on the administration on this sort of thing.”

Tax-exempt hospitals are also bracing for the spotlight. Grassley—who for years has been investigating whether hospitals with not-for-profit status are producing enough justifying community benefit—is retiring in two years. Former and current aides said his scrutiny of hospitals with massive tax benefits will continue. Throughout this year, he has kept up communication with the IRS on how the agency monitors the activity of not-for-profit hospitals.

Pharmaceuticals: ‘It’ll be busy’

If hospitals are wary about mixed financial prospects in 2019, the pharmaceutical industry is preparing for full-on political war.

Manufacturers lost a key lobbying battle in 2018 when they tried to recoup billions of dollars from the money Congress appropriated through the Medicare Part D coverage gap known as the “donut hole.”

This year will bring much more: the specifics of a proposal to control U.S. drug prices by tying them to an international price index; step therapy in Medicare Part B; and the authority for Medicare Part D insurers to exclude some protected-class drugs that are currently off limits.

If the issue is that we need to protect Medicare, I’m all in as long as Congress looks at where the real money is: hospitals and elsewhere.”

Said James Greenwood, President, and CEO of Biotechnology Innovation Organization.

“We face all of that, and then there’s the change in the majority of the House,” said James Greenwood, CEO of the Biotechnology Innovation Organization trade group. “Democrats have run very hard on the issue of drug pricing and investigation.”

There’s also Grassley, who has long been zealous on Big Pharma oversight.

“It’ll be busy,” Greenwood said.

He said he is focused on messaging and public perception of manufacturers who, he said “shoulder 95% of the rhetoric” for skyrocketing healthcare costs.

“If the issue is that we need to protect Medicare, I’m all in as long as Congress looks at where the real money is: hospitals and elsewhere,” Greenwood said.

Manufacturers are also looking to the administration’s use of executive authority for some wins, specifically on 340B where they clash most intensely with hospitals.

“There’s a lot the administration can do,” Greenwood said. “The powers they are using with the other proposals, like (the CMS Innovation Center), they can apply to the 340B program.”

Insurers: Focus on the individual market

Obamacare’s individual market premiums have stabilized but at a high price. And as Democratic progressives push a single-payer approach in the lead-up to the 2020 presidential election, insurers want to make sure the individual market can attract people who have ditched or so far avoided the exchanges because of cost.

Justine Handelman of the Blue Cross and Blue Shield Association wants Congress to try again on reinsurance funding and to look at the expansion of the tax credit subsidy, particularly to draw younger people into the exchanges.

Given the breakdown of bipartisan talks to fund reinsurance and cost-sharing reduction payments in 2018, it’s unlikely the Democratic proposal to further subsidize the exchanges will go anywhere with the Trump administration and Republican Senate.

‘Medicare for all’? This we will discuss more in the next few weeks.

Key to watch as the year unfolds is what the fallout of the ACA litigation—panned by most legal analysts but also possibly headed to the Supreme Court—will herald for both parties for healthcare ahead of 2020 when progressive Democrats want their party to embrace “Medicare for all.”

Sen. Elizabeth Warren of Massachusetts, the first Democrat to jump into the presidential race, has already made the policy part of her platform.

Progressive Democratic Reps. Ro Khanna of California and Pramila Jayapal of Washington state, who are leading the way on a new “Medicare for all” draft, plan to push a floor vote on the legislation. They told Modern Healthcare they will introduce the new version once the 676 bill number is available—a nod to the original House legislation from former Rep. John Conyers (D-Mich.).

Dems hit GOP on health care with additional ObamaCare lawsuit vote

As Jessie Hellmann noted The House on Wednesday passed a resolution backing the chamber’s recent move to defend ObamaCare against a lawsuit filed by GOP states, giving Democrats another opportunity to hit Republicans on health care.

GOP Reps. Brian Fitzpatrick (Pa.), John Katko (N.Y.) and Tom Reed (N.Y.) joined with 232 Democrats to support the measure, part of Democrats’ strategy of keeping the focus on the health care law heading into 2020. The final vote tally was 235-192.

While the House voted on Friday to formally intervene in the lawsuit as part of a larger rules package, Democrats teed up Wednesday’s resolution as a standalone measure designed to put Republicans on record with their opposition to the 2010 law.

A federal judge in Texas last month ruled in favor of the GOP-led lawsuit, saying ObamaCare as a whole is invalid. The ruling, however, will not take effect while it is appealed.

Democrats framed Wednesday’s vote as proof that Republicans don’t want to safeguard protections for people with pre-existing conditions — one of the law’s most popular provisions.

“If you support coverage for pre-existing conditions, you will support this measure to try to protect it. It’s that simple,” said Rules Committee Chairman Jim McGovern (D-Mass.) before the vote.

Most Republicans opposed the resolution, arguing it was unnecessary since the House voted last week to file the motion to intervene.

“At best, this proposal is a political exercise intended to allow the majority to reiterate their position on the Affordable Care Act,” said Rep.Tom Cole (R-Okla.). “At worst, it’s an attempt to pressure the courts, but either way, there’s no real justification for doing what the majority wishes to do today.”

The Democratic-led states defending the law are going through the process of appealing a federal judge’s decision that ObamaCare is unconstitutional because it can’t stand without the individual mandate, which Congress repealed.

Democrats were laser-focused on health care and protections for people with pre-existing conditions during the midterm elections — issues they credit with helping them win back the House.

The Trump administration has declined to defend ObamaCare in the lawsuit filed by Republican-led states, which argue that the law’s protections for people with pre-existing conditions should be overturned. It’s unusual for the DOJ to not defend standing federal law.

The House Judiciary Committee, under the new leadership of Chairman Jerrold Nadler (D-N.Y.), plans to investigate why the Department of Justice decided not to defend ObamaCare in the lawsuit.

“The judiciary committee will be investigating how the administration made this blatantly political decision and hold those responsible accountable for their actions,” Nadler said.

Democrats are also putting together proposals to undo what they describe as the Trump administration’s efforts to “sabotage” the law and depress enrollment.

“We’re determined to get that case overruled, and also determined to make sure the Affordable Care Act is stabilized so that the sabotage the Trump administration is trying to inflict ends,” said Rep. Frank Pallone Jr. (D-N.J.), chairman of the Energy and Commerce Committee, which has jurisdiction over ObamaCare.

One of the committee’s first hearings this year will focus on the impacts of the lawsuit. The hearing is expected to take place this month.

The Ways and Means Committee, under the leadership of Chairman Richard Neal (D-Mass), will also hold hearings on the lawsuit and on protections for people with pre-existing conditions.

Those two committees, along with the Education and Labor Committee, are working on legislation that would shore up ObamaCare by increasing eligibility for subsidies, blocking non-ObamaCare plans expanded by the administration and increasing outreach for open enrollment.

GOP seeks health care reboot after 2018 losses

Alexander Bolton reviewed the future strategies of the GOP. He noted that the Republicans are looking for a new message and platform to replace their longtime call to repeal and replace ObamaCare after efforts failed in the last Congress and left them empty-handed in the 2018 midterm elections.

Republican strategists concede that Democrats dominated the health care debate heading into Election Day, helping them pick up 40 seats in the House.

President Trump hammered away on immigration in the fall campaign, which helped Senate Republican candidates win in conservative states but proved less effective in suburban swing areas, which will be crucial in the 2020 election.

While Trump is focused on raising the profile of illegal immigration during a standoff over the border wall, other Republicans are quietly looking for a better strategy on health care, which is usually a top polling issue.

“Health care is such a significant part of our economy and the challenges are growing so great with the retirement of the baby boomers and the disruption brought about by ObamaCare that you can’t just cede a critically important issue to the other side,” said Whit Ayres, a Republican pollster.

“Republicans need a positive vision about what should happen to lower costs, expand access and protect pre-existing conditions,” he added. “You’ve got to be able to answer the question, ‘So what do you think we should do about health care?’ ”

A recent Associated Press-NORC Center for Public Affairs Research poll showed that 49 percent of respondents nationwide said the government should tackle health care as a top priority, second only to economic concerns.

During his 2016 presidential campaign, Trump vowed to lower prescription drug costs, but the Republican-controlled Congress over the past couple of years focused on other matters. House Democrats who are now in the majority say they are willing to work with the White House on drug pricing, but it’s unclear if Republicans will take on the powerful pharmaceutical industry, long considered a GOP ally.

Republican candidates made the repeal of ObamaCare their main message in 2010, 2012, 2014 and 2016 elections. But after repeal legislation collapsed with the late Sen.John McCain’s (R-Ariz.) famous “no” vote, the party’s message became muddled and Democrats went on the offensive.

Some Republicans continued to work on alternative legislation, such as a Medicaid block grant bill sponsored by Sens. Lindsey Graham(S.C.) and Bill Cassidy(La.), but it failed to gain much traction and the GOP health care message was left in limbo.

“We should be the guys and gals that are putting up things that make health care more affordable and more accessible,” said Jim McLaughlin, another Republican pollster. “No question Democrats had an advantage over us on health care, which they never should have had because they’re the ones that gave us the unpopular ObamaCare.”

“We need to take it to the next level,” he added. “You can’t get [ObamaCare] repealed. Let’s do things that will make health care more affordable and more accessible.”

Senate Health Committee Chairman Lamar Alexander (R-Tenn.), a close ally of Senate Majority Leader Mitch McConnell(R-Ky.), says finding an answer to that question will be his top priority in the weeks ahead.

Alexander will be meeting soon with Sen. Patty Murray(Wash.), the top Democrat on the Health Committee, as well as Sens. Chuck Grassley(R-Iowa) and Ron Wyden(D-Ore.), the leaders of the Senate Finance Committee, to explore solutions for lowering health care costs.

“I’ll be meeting with senators on reducing health care costs,” Alexander told The Hill in a recent interview. “At a time when one-half of our health care spending is unnecessary, according to the experts, we ought to be able to agree in a bipartisan way to reduce that.”

He recently announced his retirement from the Senate at the end of 2020, freeing him to devote his time to the complex and politically challenging issue of health care reform without overhanging reelection concerns.

Alexander sent a letter to the center-right leaning American Enterprise Institute and the center-left leaning Brookings Institution last month requesting recommendations by March 1 for lowering health care costs.

In Dec. 11 floor speech, Alexander signaled that Republicans want to move away from the acrimonious question of how to help people who don’t have employer-provided health insurance, a question that dominated the ObamaCare debate of the past decade, and focus instead on how to make treatment more affordable.

He noted that experts who testified before the Senate in the second half of last year estimated that 30 to 50 percent of all health care spending is unnecessary.

“The truth is we will never have lower cost health insurance until we have lower cost health care,” Alexander said on the floor. “Instead of continuing to argue over a small part of the insurance market, what we should be discussing is the high cost of health care that affects every American.”

A Senate Republican aide said GOP lawmakers are prepared to abandon the battle over the best way to regulate health insurance and focus instead on costs, which they now see as a more fundamental issue.

“There’s no point in trying to talk about health insurance anymore. Fundamentally, insurance won’t be affordable until we make health care affordable, so we have to do stuff to reduce health care costs,” said the aide.

“There are lots of things that can be done to reduce health care costs that aren’t insurance, that aren’t necessarily partisan,” the source added.

“We’re looking at ideas that aren’t necessarily partisan and don’t advance the cause of single-payer health care and don’t advance the cause of ‘only the market’ but are about addressing these drivers of health care cost and try to change the trajectory.”

Another key player is Cassidy, a physician, and member of the Health and Finance committees, who has co-sponsored at least seven bills to improve access and lower costs.

One measure Cassidy backed is co-sponsored by Sen. Tina Smith(D-Minn.) and would develop innovative ways to reduce unnecessary administrative costs.

Another measure Cassidy co-sponsored with Sens. Maria Cantwell (D-Wash.) and Tom Carper (D-Del.) would allow individuals to pay for primary-care service from a health savings account and allow taxpayers enrolled in high-deductible health plans to take a tax deduction for payments to such savings accounts.

He is also working on a draft bill to prohibit the surprise medical billing of patients.

McConnell signaled after Democrats won control of the House in November that the GOP would abandon its partisan approach to health care reform and concentrate instead on bipartisan proposals to address mounting costs, which Democratic candidates capitalized on in the fall campaign.

Asked about whether the GOP would stick with its mission to repeal ObamaCare, McConnell said: “it’s pretty obvious the Democratic House is not going to be interested in that.”

As John Bacon of USA Today reported the comprehensive health care plan unveiled by New York City Mayor Bill de Blasio this week drew applause from the Democrat’s supporters but also skepticism from those in the city who question the value and cost of the effort.

De Blasio said NYC Care will provide primary and specialty care from pediatric to geriatric to 600,000 uninsured New Yorkers. De Blasio estimated the annual cost at $100 million.

“This is the city paying for direct comprehensive care (not just ERs) for people who can’t afford it, or can’t get comprehensive Medicaid – including 300,000 undocumented New Yorkers,” Eric Phillips, spokesman for de Blasio, boasted on Twitter.

State Assemblywoman Nicole Malliotakis, a Republican representing parts of Brooklyn and Staten Island, criticized the proposal as an example of de Blasio using city coffers “like his personal ATM.”

“How about instead of giving free health care to 300,000 citizens of other countries, you lower property taxes for our senior citizens who are being forced to sell the homes they’ve lived in for decades because they can’t afford to pay your 44 percent increase in property taxes?” she said.

Seth Barron, associate editor of City Journal and project director of the NYC Initiative at the Manhattan Institute think tank, noted that the city’s uninsured, including undocumented residents, can receive treatment on demand at city hospitals. The city pays more than $8 billion to treat 1.1 million people through its New York City Health + Hospitals program, he wrote.

Barron said the mayor is simply trying to shift patients away from the emergency room and into clinics. He said that dividing $100 million by 600,000 people comes to about $170 per person, the equivalent of one doctor visit.

“Clearly, the money that the mayor is assigning to this new initiative is intended for outreach, to convince people to go to the city’s already-burdened public clinics instead of waiting until they get sick enough to need an emergency room,” Barron wrote. “That’s fine, as far as it goes, but as a transformative, revolutionary program, it resembles telling people to call the Housing Authority if they need an apartment and then pretending that the housing crisis has been solved.”

The plan expands upon the city’s MetroPlus public option plan, as well as the state’s exchange through the federal Affordable Care Act. NYC Care patients will be issued cards allowing them access to medical services, de Blasio said.

The mayor’s plan has plenty of support. Mitchell Katz, president, and CEO of NYC Health + Hospitals said the plan will help his agency “give all New Yorkers the quality care they deserve.” State Sen. James Sanders Jr., who represents parts of Queens, said he looks forward “to seeing the Care NYC program grow and prosper as it helps to create a healthier New York.”

The drumbeat for improved access to health care is not limited to New York.

California Gov. Gavin Newsom on Monday asked Congress and the White House to empower states to develop “a single-payer health system to achieve universal coverage, contain costs and promote quality and affordability.”

“We’re going to do all we can to protect health care for Washingtonians,” he said. “This public option will ensure consumers in every part of the state will have an option for high-quality, affordable coverage.”

Greg Re noted that shortly after he took office on Monday, California’s Democratic Gov. Gavin Newsom unearthed an unprecedented new health care agenda for his state, aimed at offering dramatically more benefits to illegal immigrants and protecting the embattled Affordable Care Act, which a federal judge recently struck down as unconstitutional.

The sweeping proposal appeared destined to push California — already one of the nation’s most liberal states — even further to the left, as progressive Democrats there won a veto-proof supermajority in the state legislature in November and control all statewide offices.

“People’s lives, freedom, security, the water we drink, the air we breathe — they all hang in the balance,” Newsom, 51, told supporters Monday in a tent outside the state Capitol building, as he discussed his plans to address issues from homelessness to criminal justice and the environment. “The country is watching us, the world is watching us. The future depends on us, and we will seize this moment.”

Newsom unveiled his new health-care plan hours after a protester interrupted his swearing-in ceremony to protest the murder of police Cpl. Ronil Singh shortly after Christmas Day. The suspect in Singh’s killing is an illegal immigrant with several prior arrests, and Republicans have charged that so-called “sanctuary state” policies, like the ones Newsom has championed, contributed to the murder by prohibiting state police from cooperating with federal immigration officials.

As one of his first orders of business, Newsom — who also on Monday requested that the Trump administration cooperates in the state’s efforts to convert to a single-payer system, even as he bashed the White House as corrupt and immoral — declared his intent to reinstate the ObamaCare individual mandate at the state level.

ANALYSIS: AS CALIFORNIA’S PROGRESSIVE POLICIES GET CRAZIER, WHAT’S THE SILVER LINING FOR THE GOP?

The mandate forces individuals to purchase health care coverage or pay a fee that the Supreme Court described in 2012 as a “tax,” rather than a “penalty” that would have run afoul of Congress’ authority under the Commerce Clause of the Constitution. Last month, though, a federal judge in Texas ruled the individual mandate no longer was a constitutional exercise of Congress’ taxing power because Republicans had passed legislation eliminating the tax entirely — a move, the judge said, that rendered the entire health-care law unworkable.

As that ruling works its way to what analysts say will be an inevitable Supreme Court showdown, Newsom said he would reimpose it in order to subsidize state health care.

Medi-Cal, the state’s health insurance program, now will let illegal immigrants remain on the rolls until they are 26, according to Newsom’s new agenda. The previous age cutoff was 19, as The Sacramento Bee reported.

Additionally, Newsom announced he would sign an executive order dramatically expanding the state’s Department of Health Care Services authority to negotiate drug prices, in the hopes of lowering prescription drug costs.

In his inaugural remarks, Newsom hinted that he intended to abandon the relative fiscal restraint that marked the most recent tenure of his predecessor, Jerry Brown, from 2011 to 2019. Brown sometimes rebuked progressive efforts to spend big on various social programs.

“For eight years, California has built a foundation of rock,” Newsom said. “Our job now is not to rest on that foundation. It is to build our house upon it.”

Newsom added that California will not have “one house for the rich and one for the poor, or one for the native-born and one for the rest.”

“Making sure healthcare is affordable and accessible for every Californian, including undocumented community members whom the federal government has unjustly shut out of care, is essential to reaching that vision for our future,” the organization said. “Today’s announcement is a historic step on the road toward health justice for all.”

The Sacramento Bee reported on several of Newsom’s recent hires, which seemingly signaled he’s serious about his push to bring universal health care to California. Chief of Staff Ann O’Leary worked in former President Bill Clinton’s administration on the Children’s Health Insurance Program (CHIP), which offers affordable health care to children in families who exceed the financial threshold to qualify for Medicaid, but who are too poor to buy private insurance.

And, Cabinet Secretary Ana Matosantos, who worked in the administrations of Brown and former GOP Gov. Arnold Schwarzenegger, has worked extensively to implement ObamaCare in California and also worked with the legislature to expand health-care coverage for low-income Californians.

This next year should be an exciting time if Congress and the President can figure out how to get along and how to work together to improve health care. I believe that if neither the President nor the Dems come together to solve this wall, fence, or monies for better illegal immigrant deterrents nothing will happen in healthcare and probably nothing will happen on any level. What a bunch of spoiled children!!

First, as we all are frustrated because of the government shutdown, most Federal Health Agencies are OK despite the shutdown. The FDA is feeling the pinch; IHS, ATSDR are affected also. However, it does point out the problems that Congress will face in the next 2 or more years because of political differences and the lack of civility.

News Editor Joyce Frieden pointed out that the partial shutdown of the federal government doesn’t appear to have had an immediate effect on most healthcare-related agencies, but observers expressed concern over what the shutdown might mean for the long term.

The Department of Health and Human Services (HHS), obviously the largest healthcare-related agency, has been largely unaffected by the shutdown, which began at 12:01 a.m. December 22, since most of the department is already funded through fiscal year 2019. However, the FDA is affected because its appropriations fall under a different authorization bill than the rest of HHS, so the agency had to furlough 7,053 staff members; the remaining 10,344 staff members were retained, either because they were performing functions critical to public health and safety, such as protecting ongoing experiments, or because their programs — such as tobacco regulation or new drug development — are funded by user fees.

The Alliance for a Stronger FDA — a group of patient organizations, trade associations, and pharmaceutical and biomedical companies that support adequate funding for the agency — expressed some concerns about the shutdown. “The FDA regulates products that make up 20% of consumer spending,” the organization said in a statement. “The agency’s responsibilities cannot be fully met when 7,000 employees are furloughed. Further, when the FDA is not fulfilling its critical public health responsibilities, there is no backstop to the agency’s work.”

However, “having said that, we have confidence that [FDA Commissioner] Dr. [Scott] Gottlieb and FDA leadership have ensured the emergency and critical public health and safety functions will be covered during a shutdown,” the statement continued. “Consumers should not panic — the FDA is still on the job. The immediate problem, quite a serious one, is the slowing of work on longer-term priorities and items that aren’t absolutely essential. Managing only those items that could turn into an immediate crisis is no way to run an agency that is critical to public health.”

The shutdown also hits the Indian Health Service (IHS), although direct patient care is not affected, HHS explained in its FY 2019 Contingency Staffing Plan, which was issued before the shutdown actually began. In the event of a shutdown, “IHS would continue to provide direct clinical health care services as well as referrals for contracted services that cannot be provided through IHS clinics,” the document noted. As for other IHS services, “many administrative activities are impacted due to the lapse in funding for the IHS,” a spokeswoman said in an email to MedPage Today.

Asked for examples of administrative services that IHS would continue to perform, the spokeswoman said, “The IHS can only perform administrative, oversight, and other functions that are necessary to meet the immediate needs of its patients, medical staff, and medical facilities.” Other media are reporting that some tribes will need to furlough staff and cut back services at their tribally run health clinics if the shutdown continues.

The National Institutes of Health (NIH) is largely unaffected by the shutdown except for the National Institute of Environmental Health Sciences, based in Research Triangle Park, North Carolina. There, Superfund Research Program staff are furloughed and oversight work dealing with about 50 grants is suspended, according to the staffing plan. An NIH spokeswoman confirmed in an email that no other NIH divisions have been affected.

The Agency for Toxic Substances and Disease Registry in Atlanta is another HHS division affected by the shutdown. Although the agency, which deals with environmental health threats and emergencies, will continue carrying out emergency-related functions, it cannot “support most environmental health professional training programs, continuous updating of health exposure assessments and recommendations, and technical assistance, analysis, and [provide] other support to state and local partners,” the staffing plan noted.

Susannah Luthi noted that a new single-payer health system concept will have a set of congressional hearings in the new Democratic House, and a new draft of a so-called “Medicare for all” proposal could be released as soon as next week.

Washington state progressive Democratic Rep. Pramila Jayapal, who over the summer launched the Medicare for All Caucus, said the hearings, with the support of House Speaker Nancy Pelosi (D-Calif.), will start in the House Rules and Budget committees before moving on to the House Energy and Commerce Committee.

“My goal is that these are opportunities to make the case not to the American people—the American people already had the case made to them—but to members of Congress, to really put forward what the legislation looks like,” Jayapal said Thursday after the new Congress elected Pelosi to the speakership.

“But I have the speaker’s commitment that she will help me do this, and I’ve spoken to Frank Pallone and he is not opposed,” Jayapal said. “He just hasn’t said ‘yes’ yet.”

A Pallone spokesperson did not respond to a request for comment by deadline.

Jayapal has not yet discussed possible hearings with the head of the other key health panel, Chair Richard Neal (D-Mass.) of the House Ways and Means Committee, but Neal said he is open to discussing the policy as one of the “many options that are out there” as part of holding his committee to regular order.

“That’s what committees are supposed to do, to flesh out alternatives,” Neal said.

This will be the first House hearing since the Affordable Care Act debate when the health panel of the House Committee on Education and Workforce looked at the option.

Details of the bill, a draft of which Jayapal said should be available in the next couple of weeks, are under wraps but she said it does vary from the legislation introduced by Sen. Bernie Sanders (I-Vt.) in 2017. Sanders catapulted talk of “Medicare for all” to the fore during his 2016 presidential bid and key Democratic senators has signed on to his policy since.

This is a different bill, Jayapal said. It’s largely the work of her staff and the staff of Rep. Debbie Dingell (D-Mich.), who sits on the Energy and Commerce Committee.

This new momentum for single payer—an issue that sharply divides the party—comes as Democrats are focused on defending Obamacare and as insurers hold out hope for more funding to shore up the law and draw more people into the individual market.

House Democrats will formally intervene in the lawsuit to overturn the Affordable Care Act following a Texas federal judge’s invalidation of the law—largely a political move around litigation that proved to help the Democrats in November’s elections.

In his first hearing announcement of the new Congress on Thursday, Pallone said his panel will focus on the lawsuit and its impacts. “This decision, if it is upheld, will endanger the lives of millions of Americans who could lose their health coverage,” the release from the Energy and Commerce Committee said. “It would also allow insurance companies to once again discriminate against more than 133 million Americans with pre-existing conditions.”

Judge Reed O’Connor, the Texas judge presiding over the case, ordered that the law is to remain in place as the lawsuit winds its way through the courts on appeal. It is headed next to the Fifth U.S. Circuit Court of Appeals in Louisiana.

The lawsuit was a political winner for Democrats in their campaign to reclaim the House in November, denouncing the GOP state attorneys general who filed the lawsuit and the Trump administration, which sided with the plaintiffs and refused to defend the ACA.

New Maine governor orders Medicaid expansion

Harris Meyer pointed out that the new Democratic Gov. Janet Mills signed an executive order Thursday implementing Maine’s Medicaid expansion, which was overwhelmingly approved by the state’s voters in 2017.The previous governor, Republican Paul LePage, had strongly resisted the expansion, resulting in a court battle that dragged through most of last year and ended with a judge ordering him to move forward with the Medicaid changes. In previous years, he vetoed five bills passed by the legislature to expand the program. An estimated 70,000 low-income adults will be eligible for Medicaid coverage under the expansion. Maine will become the 33rd state to extend the program under the Affordable Care Act to people with incomes up to 138% of the federal poverty level. Voters in Idaho, Nebraska and Utah approved similar Medicaid expansions.

‘Medicare for all’ advocates emboldened by ObamaCare lawsuit

Nathaniel Weixel looked at the ObamaCare lawsuit and its relationship to Medicare for All. Progressive groups and lawmakers plan to use a Texas judge’s ruling against ObamaCare to jump-start their push for “Medicare for all” in the next Congress.

Supporters of a single-payer health system are arguing that now is the time to start moving in a new direction from the Affordable Care Act, in part because they feel the 2010 health law will never be safe from Republican attempts to destroy or sabotage it.

“In light of the Republican Party’s assault, a version of Medicare for all is necessary for the future,” said Topher Spiro, vice president for health policy at the Center for American Progress. “There are just too many points of vulnerability in the current system.”

The court decision in Texas that invalidates ObamaCare in its entirety came on the heels of sweeping Democratic victories in the midterm elections, a combination that has energized advocates of Medicare for all.

“We need to do everything we can to ensure every single American has access to affordable, quality healthcare. Medicare for all has the potential to do just that as it can reduce the complexity and cost with a single payer health care system,” Rep. Debbie Dingell (D-Mich.), co-chair of the Medicare for All Caucus, said in a statement to The Hill.

Yet the effort could very well create divisions within the Democratic Party, as leaders who want to protect and strengthen the health law are reluctant to completely embrace government-run universal health insurance.

In the House and Senate, leading Democrats have said their priorities should be strengthening ObamaCare, rather than fighting over single-payer.

The lawsuit in Texas is almost certain to be overturned, they argue, and their time is better spent making sure people with pre-existing conditions remain free from discrimination by insurers.

“I think the ruling gets overturned within a couple months, so I’m not sure it matters in the long-term fight over the next generation of health-care reform,” said Sen. Chris Murphy(D-Conn.).

Sen. Ron Wyden (D-Ore.) said Democrats should focus on making sure the insurance landscape doesn’t revert to what it was before ObamaCare.

“The first thing we have to do is make sure people don’t lose what they have today — the pre-existing conditions protections — and going back to the days when there was health care for the healthy and the wealthy,” he said.

U.S. District Court Judge Reed O’Connor this month struck down the Affordable Care Act, throwing a new round of uncertainty into the fate of the law.

O’Connor ruled that the law’s individual mandate is unconstitutional, and that because the mandate cannot be separated from the rest of the law, the rest of the law is also invalid.

The court case, brought by 20 GOP-led states, was at the center of this year’s midterm campaign after Democrats attacked Republicans for supporting the lawsuit and seeking to overturn ObamaCare’s protections for pre-existing conditions.

The Trump administration, in a rare move, declined to defend the law in court, arguing instead that the pre-existing condition protections should be overturned.

“This is an outrageous, disastrous decision that threatens the health care and lives of millions of people. It must be overturned,” Sen. Bernie Sanders (I-Vt.) tweeted shortly after the decision was published. “We must move forward to make health care a right for every American.”

Rep. Ro Khanna (D-Calif.), who will be vice chairman of the House Progressive Caucus next year, said the decision “absolutely” makes a case for Medicare for all.

“There’s no doubt that would be constitutional. Medicare is already constitutional and what we’re saying is extend it to everyone, so there can be no constitutional argument,” Khanna told The Hill.

Eagan Kemp, a health-care expert with the advocacy group Public Citizen, also noted how uncontroversial Medicare is compared to ObamaCare.

“This is one more example of how tenuous the law really is,” Kemp said. “You don’t see the same type of sabotage to Medicare. So to me it highlights that the Medicare program remains the third rail of politics, so if we’re going to build a new health-care system, it’s something that can be safe.”

Some lawmakers said they understand the need to be pragmatic since centrist Democrats might not take the same message from the Texas ruling as progressives.

Khanna said he doesn’t think protecting ObamaCare from Republican attacks has to be a separate endeavor from Medicare for all.

Rep. Jan Schakowsky (D-Ill.), a member of the Medicare for All Caucus, told The Hill the fallout from the lawsuit “may help us move in an even more bold and aggressive agenda” on health care.

“We’ll see, though. I think this is the kind of issue that needs a broad consensus, may need some more outreach to the public,” Schakowsky said. “But I am interested in pursuing that agenda.”

William Cummings of USA Today, reviewed the latest wrinkle in the Obamacare sage, a federal judge on Sunday said his decision declaring the Affordable Care Act unconstitutional will not take effect while the appeals of his ruling move through the courts.

U.S. District Judge Reed O’Connor wrote in a 30-page court filing that while he believes the Fifth Circuit Court of Appeals “is unlikely to disagree” with his ruling, he agreed to stay his decision because “many everyday Americans would otherwise face great uncertainty” while the appeals play out.

On Dec. 14, O’Connor sided with a coalition of conservative states in a lawsuit challenging the constitutionality of former President Barack Obama’s signature health care law. He found that the individual mandate requiring people to buy health insurance was unconstitutional and said that meant the rest of the law was invalid as well.

In 2012, the Supreme Court upheld the law on the grounds that mandate fell within Congress’ taxation powers. When Congress removed the tax penalty for not buying insurance, that constitutional foundation was knocked out, O’Connor reasoned.

The Trump administration announced in June that it would not defend the individual mandate and other provisions of the law – such as protections for people with pre-existing conditions. But the Justice Department argued those provisions of the law could be thrown out without striking down the entire. O’Connor disagreed.

A group of Democratic states and congressional Democrats have said they plan to appeal O’Connor’s decision, which will next head to the Fifth Circuit. Although O’Connor did not grant an injunction blocking Obamacare in his initial ruling, the coalition led by California asked the judge on Dec. 17 to issue a stay and make it clear that the law will stay in place pending the appeal.

Many experts expect that appellate court to disagree with O’Connor’s ruling that the individual mandate can’t be separated from the rest of the law. If O’Connor’s ruling is upheld it is expected that the case would head to the Supreme Court.

Calif. Medical Assn. President Shares Medical Horror Story

Cheryl Clark, a contributing writer for MedPage Today wrote that the new president of the California Medical Association was expecting to spend New Year’s at a wedding in Las Vegas.

Instead, David Aizuss, MD, posted on Facebook about his “eye opening” first-hand view of “American medicine at its worst.” (The post is visible only to his Facebook friends and he declined MedPage Today‘s request to elaborate, citing ongoing “medical issues.”)

In his post, Aizuss said he was rushed by ambulance to a hospital Monday morning. “I spent hours in the emergency room where I received inadequate treatment of mind boggling pain, was never touched or examined by a physician, was mixed up with another patient and almost inadvertently transferred to another hospital, (and) was scheduled for emergency surgery based on a third patient’s lab work that was confused with mine,” he wrote.

He “finally signed out of the hospital against medical advice so I could obtain care from physicians that I know and trust.” He did not name the hospital.

Aizuss, an ophthalmologist who practices in Calabasas, northwest of Los Angeles, posted his complaint New Year’s Eve, apparently while at the LAX International airport in Los Angeles, where he said he was “just returning from Las Vegas where we were supposed to attend a wedding.”

Dozens of Facebook friends, several apparently also physicians, expressed their shock that the CMA president could receive such poor emergency room response, and some said they were happy he was speaking out about poor quality of hospital care.

“If you get terrible care like this (at least you know the difference) think about the care that Joe Sixpack gets; he doesn’t have the resources to get better care. This system is broken and we need to fix it,” posted one.

Wrote another, “As president of the CMA, your voice can be loud! Don’t be timid and do not be afraid of making enemies. Remember our patients know and respect us when we stand against poor medicine.”

Aizuss ended the post by saying, “Truly an eye-opening experience for the President of the California Medical Association. Happy New Year to all!”

He began his one-year term as CMA president in mid-October, saying he wanted to focus on physician burnout, practice sustainability, and payment. He is also past chairman of the CMA Board of Trustees.

He is a medical staff member at Tarzana Hospital and West Hills Hospital, in Los Angeles County, and serves as an assistant clinical professor of ophthalmology at the UCLA Geffen School of Medicine.

The CMA represents about 43,000 physicians in the state and is the second largest organized medicine group of any state, next to the Texas Medical Association, which represents about 52,000 physicians.

Why did I end with this article? It points out the fact that whatever the politics, we all have to continue to forge a better health care system. We need to get rid of the biases and the politics and strive, no demand a better healthcare delivery system. But we also have to realize that it will take some radicle changes, but it will be worth it in the end.

Let us continue the research and discussion into what the healthcare system will look like in our future!

As the end of the year approaches I thought that I would try to review some of the progress, if I can find any. Probably the biggest invisible improvements the world sees year to year are essential indicators of overall global public health, like rates of infant mortality, maternal mortality, childhood stunting, and teen pregnancy. These are important, because they represent access the average person alive has to health-care professionals, facilities, medicine, and more. All of these rates have been falling in the past few decades, in some cases dramatically, and every single one fell again in 2018.

There is one strong positive note. An overriding public health finding is that people are living longer. “If that’s not a bottom line reason for optimism,” says Dr. Ashish Jha, director of the Harvard Global Health Institute and the T.H. Chan School of Public Health, “I don’t know what is.”

And then there are the million-plus cases of cholera in Yemen — deemed “a hideous milestone for the 21st century” by the International Committee of the Red Cross.

Note: Because of the way global numbers are gathered, it’s too soon to report on health statistics from the year now drawing to a close. There are only a few yet available for 2018 — polio cases, for example, and Ebola deaths in Democratic Republic of the Congo.

But there has been a constant stream of numbers released from the years just past. Unless otherwise noted, the numbers below represent the worldwide population.

7 Of Our Most Popular Global Health and Development Stories Of 2018

Life Expectancy

Worldwide life expectancy in 2016 was 72 years, up from 66.5 years in 2000.

The gain of 5.5 years in worldwide life expectancy between 2000 and 2016 was the fastest gain since the 1960s and reversed the declines of the 1990s caused by AIDS in Africa and the fall of the Soviet Union.

But life expectancy has been ticking down in the U.S. for three years: it was 78.9 in 2014; 78.8 in 2015; 78.7 in 2016; and 78.6 in 2017. An increase in deaths from opioids and from suicide is a possible reason for the trend.

Child mortality rates for children under five years of age have fallen from 216 deaths per 1,000 live births in 1950; to 93 deaths per 1,000 live births in 1990; to 40.5 deaths per 1,000 in 2016; and most recently to 39.1 deaths per 1,000 live births in 2017.

Health Care

3.6 million people died in 2016 because they had no access to health care.

5 million people, despite having access to health care, died in 2016 because the quality of care they received was poor.

In 2010, the year that the Affordable Care Act was signed into law, 49.9 million people in the United States, or 16.3 percent of the population under age 65, were without health insurance. In 2017, that number dropped to 28.9 million uninsured, or 10.7 percent of that segment of the population.

Yet also in 2017, the number of uninsured Americans increased by nearly half a million — the first increase since the Affordable Care Act was implemented.

HIV/AIDS

36.9 million people were living with HIV in 2017.

940,000 people died of AIDS-related illnesses in 2017.

35.4 million people have died from AIDS-related illnesses since the epidemic was identified in 1981.

Ebola

11,325 people died of Ebola in the epidemic of 2014-2016 in West Africa.

As of Dec. 23, there have been 347 confirmed deaths so far in the current Ebola outbreak in the Democratic Republic of Congo.

Air Quality

Pollution contributed to the deaths of some 9.9 million people in 2015 by causing diseases such cancer, heart disease and respiratory illnesses. That’s three times more deaths than the death toll from AIDS, tuberculosis and malaria combined.

Murder

Roughly 385,000 people were murdered around the world in 2017.

Hunger

Some 821 million people around the world did not get enough to eat in 2017. resulting in malnutrition, and about 151 million children under five experienced stunted growth due to malnutrition.

An estimated 1.9 billion adults were overweight or obese in 2016. 41 million children under five are overweight or obese.

Cholera

There were 1,207,596 suspected cases of cholera in Yemen between April 2017 and April 2018.

The total estimated number of cholera cases worldwide ranges from 1.4 million to 4 million.

Vaccinations

Global vaccination rates against childhood diseases in 2017: 85 percent. That number has stayed steady for several years.

In 2017, about 100,000 children in the U.S. under two, or 1.3 percent of children that age, had not been vaccinated against serious diseases like measles and whooping cough.

The percentage of unvaccinated U.S. children has quadrupled from 0.3 percent in 2001 — shortly after the circulation of erroneous and disproven reports that vaccines cause autism.

Polio

The number of cases of polio worldwide in 2018 as of Dec. 25 was 29, compared to 22 in 2017. There were an estimated 350,000 cases around the world in 1988.

A mysterious polio-like disease, called acute flaccid myelitis that can paralyze patients, mostly children, appeared in the U.S. in 2014 with 120 confirmed cases from August to December. There were 22 confirmed cases in 2015, 149 confirmed cases in 2016, 35 confirmed cases is 2017 and 182 cases as of Dec. 21, 2018.

Guinea Worm

In 1986, guinea worm disease, an incapacitating disease that creates painful lesions, affected some 3.5 million people in Africa and Asia. As of Oct. 1, 2018, there were 25 reported cases of guinea worm disease worldwide: 1 in Angola; 14 in Chad, and 10 in South Sudan. One obstacle to wiping it out entirely: The worm can circulate in dogs.

Mystery Disease

Number of cases of Disease X: Zero. But that doesn’t mean the World Health Organization isn’t worried about it. They use the term Disease X to refer to a pathogen “pathogen currently unknown to cause human disease” but that has the potential one day to trigger a deadly pandemic.

Healthcare in Congress for 2019: All Hat, No Cattle, Experts Say

News Editor, Joyce Frieden, in her end of the year report, noted that the work Congress does on healthcare next year — and even the year after — will be mostly for show without a lot of concrete results, experts said.

“Probably nothing is going to happen legislatively in the next 2 years around healthcare” in terms of legislation that is actually passed by both the House and Senate and signed by the president, said Chris Sloan, a director at Avalere, a healthcare consulting firm, in a phone interview. “I think the Democrats in the House are going to use this as an opportunity to showcase their policy priorities for 2020 — things like ‘Medicare for All’ or a Medicare buy-in, taking votes on those and nailing down some specifics.”

“You will also see Democrats in the House use their oversight power over [the Department of] Health and Human Services (HHS) — to hold hearings, and give pushback around things the administration is doing around the Affordable Care Act (ACA) like the expansion of association health plans and cuts in funding for marketing and outreach in the [health insurance] exchanges,” he said.

Sloan also expects a lot of activity to occur around drug pricing. “I’m not expecting a major piece of legislation around drug pricing coming out, but it’s a huge issue with a lot of traction on the right and the left… so I’d expect in the House and the Senate [to see] hearings on drug pricing,” he said. “There’s always a chance that the Democratic House and the Republican president will come together on some piece of drug pricing — like transparency reporting — but I think it’s unlikely. So the next 2 years won’t be stagnant for healthcare; there will be a lot of policy development but no major bills.”

Julius Hobson, Jr., JD, senior policy advisor at Polsinelli, a consulting firm here, was a little more optimistic — but only a little. “The first thing on my list is prescription drug pricing,” he said in a phone interview. “If there is an opportunity for Republicans and Democrats to work out something together — provided neither side tries to overreach — that will be the one thing that has the possibility of being enacted.” Possibilities for drug pricing legislation include bills supporting reimportation, pegging U.S. drug prices to those in Europe, or giving HHS the authority to negotiate drug prices under Medicare and Medicaid.

“After that, I can’t find a health issue at the moment that I think the two sides could work on,” Hobson said. “But I think we’ll see more hearings on the oversight of the ACA, especially in the House, as administration officials get dragged in to see what they’re doing.” A House floor vote on a ‘Medicare for All’ bill is also a possibility — although it won’t pass — along with more oversight on veterans’ healthcare, he added.

One area that gets little attention is healthcare costs at the Department of Defense, which is the fastest-growing portion of the budget, said Hobson. “Having been in wars for 17 years, our healthcare costs are going through the roof.” Both President George W. Bush and President Obama pushed for having military members pay more of their costs under the Tricare health insurance program for military families, “but Congress refused to do that.”

Instead of action in Congress, most of the activity on the healthcare front will probably be within the Trump administration, he continued. “There will be more attempts to get things done — things [the administration] can do that Congress is unable to do.” Expect more efforts to come from the Office of Regulatory Reform at the Centers for Medicare & Medicaid Services, “which is consistent with an executive order from last year to come up with lists of regulations they could do away with to make the system less burdensome,” Hobson predicted.

Rodney Whitlock, vice president for health policy at ML Strategies, a consulting firm here, said in a phone interview that he expected some effort to pass a bill related to Texas vs. the United States of America — the court case questioning the constitutionality of the ACA — “and I think there’s something that looks a little more like ACA stabilization in the works… [The question is] what is the difference between the things where they’re trying to make a point versus what might be actually statutorily possible.”

Bob Laszewski, president of Health Policy and Strategy Associates, a consulting firm in Alexandria, Va., agreed with the idea that both parties will be focused on the drug pricing issue. “This seems to be about the only bipartisan interest and it will be interesting to see if there is any real agreement between them,” he said in an email. “Trump’s reference pricing proposal could be an interesting spot — will he find more Democratic allies than Republicans?”

Healthcare-related taxes imposed by the ACA but not yet implemented — including taxes on “Cadillac” health insurance plans and medical devices — are another possible area of cooperation, he said. “These have only been postponed and will have to be dealt with. There does seem to be broad agreement they should not be restarted.” And the pharmaceutical industry will be pushing back against a proposal to have it pay a larger share of drug costs in the Medicare Part D “donut hole,” he added.

Finally, “Democrats will have as their top priority rubbing salt into the Republican wounds on pre-existing conditions and the recent Texas court case,” Laszewski said. “I don’t see any opportunity for bipartisan fixes. With the Supreme Court more than a year away in terms of any final decision, this will be a very dark cloud in 2019.”

Bookended by Obamacare, 2018 was the year of policy change

As Susannah Luthi points out in 2018 tith Congress’ attempt to repeal the Affordable Care Act dead by the end of 2017, any relief the law’s supporters felt were likely short-lived, as 2018 was the year the Trump administration began significantly remolding a law it fundamentally opposes.

Led by HHS Secretary Alex Azar, who took the reins of the $1.2 trillion department last January, the administration charted an overarching strategy to lower drug prices and reduce spending on hospital care. Moreover, by the end of 2018, the entire Affordable Care Act was back in legal peril when a federal judge in Texas struck it down and blocked immediate appeal.

Here’s a look at the major healthcare political issues of 2018, a year when the public political drama slowed down, but activity aiming to overhaul the ACA sped up.

Drug prices

During Azar’s confirmation hearing last January, he faced skeptical Senate Democrats who argued his tenure as a top executive with pharmaceutical giant Eli Lilly & Co. could blunt the Trump administration’s promised plan to lower drug prices.

The skepticism didn’t abate when White House in May unveiled its blueprint. But as the policy bones gained muscle, Azar’s ideas have won over some doubters and drawn manufacturer ire.

“The biggest news item of the year is that the drug blueprint wasn’t hot air and that they’re really trying to do big things,” said Michael Adelberg, a healthcare consultant with the law firm Faegre Baker Daniels. “Like many others, I assumed it was mostly PR, but I think the administration deserves credit for taking this seriously.”

Among the most controversial policies: a mandatory international pricing index model for Part B physician-administered drugs to align prices with those in other countries.

Critics on the left who want Medicare to negotiate directly said the policy falls short. Investment analysts hope the proposal is a tactic to bring manufacturers to the negotiating table.

Critics on the right say it’s price-fixing.

“Proposing to effectively accept the pricing decisions of other countries, while having the chutzpah to brand the policy ‘market-based’ is beyond disappointing,” said Benedic Ippolito of the American Enterprise Institute.

Last month the administration also proposed a significant change to Medicare Part D that sparked outcry: room for price negotiation for drugs in protected classes, where Medicare costs are exceptionally high. Patient groups are fighting back over concerns about access, but the administration says Part D has substantial patient protections in place, and the chronically ill will always be able to get critical medications.

Site-neutral payments

HHS has also took action on site-neutral payments for Medicare, and despite pending litigation, analysts believe the political winds on the issue may have changed.

Last month the administration finalized a rule that will slash payments for office visits at hospital outpatient clinics to match the rate for independent physicians’ offices. In response, two powerful industry groups sued.

But nonpartisan experts have wanted to see this policy move—not only to address rising Medicare expenses but also consolidation and the rising costs that stem from that trend. “In an era of growing consolidation of providers and increasing physician employment by hospitals, site-neutral payments are critical on all dimensions,” said Paul Ginsberg, director of the USC-Brookings Schaeffer Initiative for Health Policy at the Brookings Institution.

Hospitals will keep fighting hard against them, Ginsberg added. But from his vantage point, analysts’ views on the issue have expanded to what’s at stake for the entire healthcare system in terms of this policy, and they are increasingly bipartisan.

“I’ve had the sense that (the administration) has long seen the issue of healthcare competition as something they can work with Democrats on,” he added. “And I think Democrats are much more comfortable using competition than they have been historically. So that’s a political dimension that makes it more promising that this policy could be sustained.”

340B program

The administration also trimmed reimbursement in the 340B drug discount program, which avoided congressional reforms despite Senate hearings and introduction of several House bills.

Hospitals had a key win late this year when HHS jumped ahead of its stated deadline and said it will start capping the prices manufacturers can charge providers for drugs. Regulation over ceiling prices for 340B has been delayed for years and early this fall hospitals sued over the latest postponement.

But litigation over the sweeping cuts to Part B drug reimbursements for 340B hospitals is still pending, and the administration has expanded those cuts to hospital systems’ off-campus facilities.

Affordable Care Act

A proposal to stabilize the individual market with a federal funding boost fell apart early in the year as a band of Republican-led states sued to overturn the law following the effective elimination of the individual mandate penalty for 2019.

Still, Obamacare may survive this attack. Sabrina Corlette, from Georgetown University’s Center on Health Insurance Reforms, said that in 2018 the law proved the doubters wrong. “It revealed remarkable resilience in the face of some pretty dramatic attempts to roll back or undo the law,” she said.

The individual market remains in a holding pattern. Shortly before open enrollment started this year, CMS Administrator Seema Verma touted the fact that premiums dropped for the first time since the law was implemented.

Premiums for benchmark silver plans on the federal individual market exchanges will drop in 2019, marking the first decrease since the Affordable Care Act was implemented, CMS Administrator Seema Verma announced on Thursday.

Tennessee will see the sharpest premium decline, as average monthly premiums for silver plans fell more than 26%, from more than $600 last year to $449. North Dakota had the greatest increase, with average premiums rising more than 20% from $312 per month to $375. Sixteen of the 39 states using the federal exchange will see declines, two states will have no change and the majority of the remaining states will face marginal, single-digit increases.

Verma dismissed the idea that President Donald Trump’s cut-off last year of the cost-sharing reduction payments hurt the market, although the action was followed by a nearly 40% jump in average premiums as insurers added the cost to benchmark silver plans in a move known as “silver loading.”

Analysts have credited the slim premium increases insurers have announced so far this year as a correction to excessive 2018 rate hikes.

But Verma defended the expansion of short-term, limited duration plans as an affordable option for people who can’t afford Obamacare plans. Potentially, they could appeal to the 20 million Americans who don’t have coverage, she added.

“The prediction was that the offering of short-term plans would have negative impact on the market and increase premiums, but we’re not seeing the impact on the market,” Verma said.

The administrator also announced the administration will be writing new guidance for 1332 waivers to allow states to broaden exchange plan design “to create more affordable options,” but said the new reinsurance programs are a key part of the overall drop in premiums.

Federal exchange states that launch reinsurance programs in 2019 will see decreases in premiums as expected, but prices will not fall to pre-2018 levels. Wisconsin, which had its 1332 waiver approved earlier this year, will see a drop in averages from $464 in 2018 to $440 for 2019. In 2017, average silver plan premiums in the state were just over $300. Maine’s average premiums will decline from $482 in 2018 to $446 in 2019, still more than $100 per month higher than the $316 in 2017.

New Jersey will see the sharpest decrease with its reinsurance waiver. In 2017, average silver premiums were $286 per month, rising to $339 per month this year. With reinsurance, they will settle in at $286 per month in 2019.

Last year, Alaska — which has the highest insurance premiums in the country — saw a drastic decline after implementation of its waiver. Average monthly premiums fell from $759 in 2017 to $595 in 2018. Next year they will drop again to $576.

The CMS hasn’t made enrollment projections for 2019 based on these new numbers, but Verma added that more people may opt for the federal exchanges “when we’re not seeing double-digit rate increases.”

Verma said the administration still wants changes to Obamacare’s exchange rules.

“For millions of people, the law needs to change,” she told reporters. ” While some have publicly been accusing us of sabotage, we have been doing everything we can to mitigate problems of Obamacare.”

The high cost of stabilization continues to trouble many. “ACA markets have stabilized at an unsatisfactory point,” said Douglas Holtz-Eakin, a conservative economist and former director of the Congressional Budget Office.

He said the deep cuts to marketing and other changes “all do matter at the margins” and that the slower enrollments noted this year have borne this out. “You have to decide what the administration’s objective is politically,” he added. “They don’t want to expand enrollment: they want it stabilizing,” but it’s coming at a high cost.

Adelberg said while plans aren’t “hemorrhaging money and going out of business” as they were in the early years, the exchange market still very much depends on subsidies and looks more like a tier of Medicaid.

“The exchange market is starting to look like Medicaid expansion-expansion,” he said.

The CMS has tweaked guidance for Section 1332 state innovation waivers, sparking criticism that the administration opened the door to trimming protections.

Potential actions from the administration take on extra weigh in light of the late-breaking court decision over Obamacare.

But even strong critics of the law doubt the administration would use the murky legal situation to cross statutory lines with waiver approvals in the meantime.

“No one wants to do anything in the interim, and both sides are waiting for the final, final decision,” said conservative policy analyst Chris Jacobs.

Medicaid public option

States this year started a serious push for their own form of the public option through Medicaid and some in Washington have started paying attention.

Minnesota, Nevada and New Mexico are some of the states that have forged ahead with studies on this policy. And with congressional activity on healthcare likely on hold until after the 2020 presidential election, advocates see this year’s progress on the state level with this policy as significant—even if the industry is on the alert about potential revenue hits.
Adelberg said he is tracking the discussion closely and is particularly interested in the option if it’s offered outside the Obamacare exchanges

I have previously stated and I will restate my opinion, that unless civility, maturity, and a dedication to do what is best for the voters, nothing will get done in healthcare in the next 2 years with the Democrats using the failure as one of many talking points to get elected. These will be depressing 2 or more years of frustration. But I will continue my discussion regarding the options for our healthcare system and hopefully offer what I believe is the best form of healthcare delivery for all in our wonderful country.

Tim Dominguez sits under the freeway after escaping the Borderline Bar and Grill in Thousand Oaks, Calif., where a gunman killed 12 other people Wednesday night.

According to statistics from the Gun Violence Archive, there have been 307 mass shootings in the 312 days of 2018. They are a commonplace occurrence. This is a horrifying thing to say, but it is the truth. We need to say this truth over and over. We need to face this horror without looking away. We live in a country where there are relatively few restrictions on gun ownership and where our cultural tolerance for mass murder appears to be infinite.

Less than a month ago an author visited California State University Channel Islands, not far from where the shooting on Wednesday night took place. A deeply engaged audience greeted her. They had a thoughtful discussion about sexual violence, justice, trauma, and healing. Some of those students might have been at the Borderline Bar and Grill in Thousand Oaks, Calif., Wednesday night, doing what college students are supposed to be doing — dancing and hanging out with friends, having fun. As she read the news Thursday morning, her chest tightened. She read quotes from students from that campus describing the sparks and the smoke they saw. She felt resignation creeping in.

Over the past two years, there has been increased security at his events, armed guards. Sometimes they are there because he had received a threat. Sometimes they are there because she is a black woman with opinions and the threat is already implied. Every time she goes on stage, she looks out into the audience and wonders if there is a man with a gun in the sea of faces. She is not scared of him. She is resigned to the inevitability of him pointing that gun at me, at the crowd, and pulling the trigger. She doesn’t want to be this resigned. She doesn’t want you to be, either.

In an interview, the father of one of the young women who escaped the carnage at the Borderline Bar said his daughter did what he has taught her to do in the event of a mass shooting. It took me a moment to realize what he was saying. We are raising generations of children who are prepared for this kind of crime.

It is a peculiarly American affliction that this epidemic of gun violence doesn’t move us to take any real steps toward curbing gun violence and access to guns.

It is painfully obvious that there is no shooting appalling enough to make American politicians stand up to the National Rifle Association and gun makers. A congressman was shot and critically wounded. Children at Sandy Hook Elementary were murdered. Revelers at the Pulse nightclub were murdered. Concertgoers in Las Vegas were murdered.

Our leaders think and pray their way through the horror. The politicians who rely on N.R.A. donations feign concern and continue taking that money. American voters keep these people in office, perhaps, because it isn’t their loved ones being murdered. Yet. And even if it were, I don’t know that their votes would change. Instead, people treat the Constitution like a fast-food value menu, choosing which amendments are sacrosanct (the First and Second) and which are disposable (any of those giving civil rights to anyone but white men).

The script following these shootings is too familiar — flags at half-staff, hollow words of sympathy — but what chills me is the relatively calm eloquence of the survivors speaking to reporters. How they don’t seem particularly surprised to have survived a mass shooting. That they are able, in the immediate aftermath of trauma, to articulate their experiences. They can do this because they have seen it done.

How do we change this script? How do we convince enough people that we are well past the time for radical action?

We must elect politicians who will ban assault weapons and at the very least enact legislation requiring federal, rigorous background checks for gun owners. But really, that’s not radical. It’s the bare minimum, and by the grace of that kind of legislation in California, the shooter was able to use only a handgun. This massacre where 13 people died could have been much worse.

In late September, I went to a gun range with my brother, who is a gun enthusiast. We spent about an hour shooting guns as he explained the merits of the various weapons. We wore safety goggles, and though it wasn’t my first time shooting a gun, he went over the safety protocols. Before we could even enter the range we watched a safety video. From the moment we entered the facility until the time we left, we were reminded of the danger of these weapons. Each gun was heavy in my hand, hot. Before long, the space around us was thick with the stench of oil and gunpowder. We were shooting at targets, metal, and paper. There was a certain satisfaction when I shot well. I understood the appeal of holding that kind of power in the palm of my hand. I also understood the responsibility of holding a gun. I was awed by it. I was not so enamored that I want to own a gun myself. Yet.

Today I held a 4-month-old baby. He is cute and strong and wide-eyed. He still smells sweet and new. I held him and for a few minutes, I forgot about everything terrible. I forgot about the man with a gun and the 12 other people he killed and the people he injured. I forgot about the man with a gun who walked into a yoga studio and started shooting. I forgot about the man with a gun who walked into a grocery store and started shooting. I forgot about the man with a gun who walked into a synagogue and started shooting. And then I looked at this baby’s tiny face and his wide, gummy smile. I remembered everything terrible. I understood the responsibility of holding a child. I was awed by it. I realized that as horrifying and commonplace and inevitable as mass shootings are, we cannot do nothing. Stare into the horror. Feel it. Feel it so much that you are moved to act.

Deaths From Gun Violence: How The U.S. Compares With The Rest Of The World

Nurith Aizenman reported these statistics about a year ago but I thought that the story and the comparisons were relevant regarding gun violence rates. The timing of that report couldn’t be more apt — or grimmer even today. The statistics were released just as Americans were waking up to the news that a gunman had opened fire the night before at the Borderline Bar and Grill in Thousand Oaks, Calif. He killed 12 people and was found dead at the scene.

The attack came just 11 days after the fatal shooting that claimed 11 lives at Pittsburgh’s Tree of Life synagogue. Eight months before that, a gunman shot 17 people dead at Marjory Stoneman Douglas High School in Parkland, Fla. And just over a year ago a gunman massacred 58 people at a music festival in Las Vegas.

As in previous years, the University of Washington’s latest data indicates that this level of gun violence in a well-off country is a particularly American phenomenon.

When you consider countries with the top indicators of socioeconomic success — income per person and average education level, for instance — the United States is bested by just 18 nations, including Denmark, the Netherlands, Canada, and Japan.

Those countries all also enjoy low rates of gun violence. But the U.S. has the 28th-highest rate in the world: 4.43 deaths due to gun violence per 100,000 people in 2017. That was nine times as high as the rate in Canada, which had 0.47 deaths per 100,000 people — and 29 times as high as in Denmark, which had 0.15 deaths per 100,000.

The numbers come from a massive database maintained by the University’s Institute for Health Metrics and Evaluation, which tracks lives lost in every country, every year, by every possible cause of death. The 2017 figures paint a fairly rosy picture for much of the world, with deaths due to gun violence rare even in many countries that are extremely poor — such as Bangladesh, which saw 0.07 deaths per 100,000 people.

Prosperous Asian countries such as Singapore and Japan boast the absolute lowest rates, though the United Kingdom and Germany are in almost as good shape.

“It is a little surprising that a country like ours should have this level of gun violence,” Ali Mokdad, a professor of global health and epidemiology at the IHME, told NPR in an interview last year. “If you compare us to other well-off countries, we really stand out.”

To be sure, there are quite a few countries where gun violence is a substantially larger problem than in the United States — particularly in Central America and the Caribbean. Mokdad said a major driver is the large presence of gangs and drug trafficking. “The gangs and drug traffickers fight among themselves to get more territory, and they fight the police,” said Mokdad. And citizens who are not involved are often caught in the crossfire. Another country with widespread gun violence is Venezuela, which has been grappling with political unrest and an economic meltdown.

Mokdad said drug trafficking may also be a driving factor in two Asian countries that have unusually high rates of violent gun deaths for their region, the Philippines and Thailand.

With the casualties due to armed conflicts factored out, even in conflict-ridden regions such as the Middle East, the U.S. rate is worse.

The U.S. gun violence death rate is also higher than in nearly all countries in sub-Saharan Africa, including many that are among the world’s poorest.

One more way to consider these data: The institute also estimates what it would expect a country’s rate of gun violence deaths to be based solely on its socioeconomic status. By that measure, the U.S. should be seeing only 0.46 deaths per 100,000 people. Instead, its actual rate of 4.43 deaths per 100,000 is almost 10 times as high.

Dems vow swift action on gun reform next year

Mike Lillis and Scott Wong wrote that the nation’s latest mass shooting has rekindled the fire under Democrats to use their newly won majority to strengthen federal gun laws in the next Congress.

The issue was off the table for eight years of Republican rule, as GOP leaders have sided with the powerful gun lobby against any new gun restrictions.

But House Minority Leader Nancy Pelosi(D-Calif.), who’s seeking to regain the Speaker’s gavel, vowed to move quickly on gun reform next year, citing Wednesday night’s shooting massacre at a California country music bar as the latest reason Congress should step in with new restrictions on the sale and ownership of firearms.

Universal background checks, Pelosi suggested, would be the likely first step.

“It doesn’t cover everything, but it will save many lives,” Pelosi said Thursday night on CNN’s “Cuomo Prime Time” program.

“This will be a priority for us going into the next Congress.”

Rep. Jerrold Nadler (D-N.Y.), likely the incoming chairman of the House Judiciary Committee, said this week that he’ll “immediately get to work” on that legislation next year.

That position marks a shift from almost a decade ago when Democrats last controlled the House and party leaders declined to consider tougher gun laws despite entreaties from some rank-and-file members.

Rep. Mike Quigley (D-Ill.), a gun reformer from Chicago and member of the Judiciary Committee, had requested hearings on background checks in 2010, only to be refused.

The reasons were largely political: House Democrats, at the time, had a more conservative-leaning caucus, boasting more than 50 Blue Dogs in battleground districts the party was fighting to preserve.

After a 10-year ban on assault weapons signed by former President Clinton was widely viewed as a “third rail” that helped secure George W. Bush’s White House victory in 2000, Democrats didn’t want to repeat history.

Since then, the country has seen a long string of prominent mass shootings, including violence targeting a congresswoman in Tucson, Ariz., elementary school students in Newtown, Conn., nightclubbers in Orlando, churchgoers in Charleston, S.C., country music fans in Las Vegas, high schoolers in Parkland, Fla. and Jews praying at a synagogue in Pittsburgh last month.

The most recent tragedy occurred Wednesday night at a bar in Thousand Oaks, Calif., where authorities say a Marine combat veteran killed 12 people before fatally shooting himself.

One of the victims, 27-year-old Telemachus Orfanos, survived last year’s Las Vegas massacre but was killed in the Thousand Oaks shooting.

“I don’t want prayers. I don’t want thoughts. I want gun control, and I hope to God nobody else sends me any more prayers,” Orfanos’s mother, Susan Orfanos, said in an emotional interview with KABC that has been viewed millions of times on social media. “I want gun control. No more guns.”

The rash of devastating episodes shifted public sentiment in strong favor of gun reform, and polls show overwhelming support for measures like expanded background checks among voters of all political stripes.

Three Parts Brands Have Come Together

The Ford Motor Company reported that among the host of Democrats elected to the House on Tuesday in conservative districts, many embraced new restrictions on gun purchases without facing the previously feared backlash at the polls.

“The public has evolved on their belief about this, given the magnitude and disparity of gun violence and mass shootings,” Quigley said Friday by phone.

The Democrats’ plans for gun-reform legislation remain unclear.

Rep. Mike Thompson (D-Calif.), the head of the party’s task force to prevent gun violence, has taken the lead on the background check bill, and will likely do so again next year. There are also dozens of related proposals other lawmakers will surely promote, including bills to ban bump stocks, eliminate assault weapons, spike taxes on guns and ammunition and prohibit high-capacity magazines like the one allegedly used by the shooter in Thousand Oaks.

Quigley is all for pushing bold reforms, including a ban on assault weapons, but is promoting the idea of securing early victories on more popular measures.

“Let’s start where we have some commonality,” he said. “The vast majority of Americans, the majority of gun owners, the majority of NRA [National Rifle Association] members support universal background checks.

“That’s a good place to start.”

That the House will pass some kind of background-checks legislation is clear. But any new gun restrictions face tall odds in the GOP-controlled Senate, where Republicans are near unanimous in their opposition to such reforms.

In 2013, in the wake of the Sandy Hook Elementary School shooting in Newtown, Sens. Pat Toomey (R-Pa.) and Joe Manchin (D-W.Va.) authored legislation to expand background checks for firearms purchased online and at gun shows. It fell six votes short of overcoming a GOP-led filibuster, with only four Republicans — Toomey, and Sens. Susan Collins (Maine), John McCain (Ariz.) and Mark Kirk(Ill.) — supporting the measure.

Kirk lost his reelection bid in 2016 and McCain died this year, leaving just two Senate Republicans who back strengthening background checks. Manchin just won re-election this week and Toomey isn’t up for reelection until 2022.

“Senator Toomey is continuing to work with his colleagues in the Senate to find a path forward to 60 votes for his background check legislation,” said Toomey spokesman Sam Fischer.

Complicating the math for gun reform supporters, Tuesday’s midterms added to the GOP Senate majority, and the incoming Republicans are all gun-rights promoters supported heavily by the firearms lobby.

Asked about the appropriate response to the Thousand Oaks shooting, Sen.-elect Marsha Blackburn(R-Tenn.) was terse.

“What we do is say, how do we make certain that we protect the Second Amendment and protect our citizens?” Blackburn told Fox News on Thursday.

President Trump could be a wild card in the coming gun debate. The president has a long and conflicting history on the topic, from the promotion of an assault-weapons ban years ago to a more recent embrace of the Second Amendment protectionism advocated by the NRA.

Gun-reform advocates, long accustomed to congressional inaction on the issue, say they’ve been encouraged by what they’ve heard from Pelosi and other Democratic leaders so far.

“While so many other factors have not been settled, we believe that House Democrats will move universal background checks in early 2019,” said Robin Lloyd, government affairs director for the Courage to Fight Gun Violence, the gun-reform group led by former Rep. Gabrielle Giffords (D-Ariz.), the congresswoman shot in the head in Tucson in 2011.

Medical professionals to NRA: Guns are our lane. Help us reduce deaths or move over.

Megan L. Ranney, Heather Sher, and Dara Kass, Opinion contributors, reported that after the American College of Physicians released a paper last week about reducing firearm injuries and deaths in America, the NRA tweeted the statement: “Someone should tell self-important anti-gun doctors to stay in their lane.”

A couple of days later, the Centers for Disease Control published new data indicating that the death toll from gun violence in our nation continues to rise. As the NRA demanded that we doctors stay in our lane, we awoke to learn of the 307th mass shooting in 2018 with another 12 innocent lives lost to an entirely preventable cause of death — gun violence.

Every medical professional practicing in the United States has seen enough gun violence firsthand to deeply understand the toll that this public health epidemic is taking on our children, families, and entire communities.

It is long past time for us to acknowledge the epidemic is real, devastating, and has root causes that can be addressed to assuage the damage. We must all come together to find meaningful solutions to this very American problem.

We bear witness to every gun-related trauma

The physicians, nurses, therapists, medical professionals, and other concerned community members signing this letter are absolutely “in our lane” when we propose solutions to prevent death and disability from gun violence.

As the professionals who manage this epidemic, we bear witness to every trauma and attempt to resuscitate, successful or not.

►We cut open chests and hold hearts in our hands in the hopes of bringing them back to life.

►We do our best to repair the damage from bullets to pulverized organs and splintered bones.

►We care for the survivors of firearm injury for decades after they’ve been paralyzed, lost a limb, or been disabled.

►We deliver mental health care to the siblings and parents of the children who have been shot as well as to the survivors of gun violence.

►We treat the anxiety of teachers and students who are already traumatized by the news of mass shootings who are then are asked to participate in active shooter drills in their own schools.

►We prepare for mass casualty shootings with drills ourselves and practice sorting victims by how life-threatening their injuries are while fervently hoping that a mass shooting never touches our own communities.

►We are asked by families, schools, employers and law enforcement to conduct mental health evaluations and threat assessments of individuals who demonstrate dangerous behaviors with legally-owned firearms — yet we have no protocols to decrease firearm risk when they present to us.

►We support our own medical colleagues as they themselves must recover from the psychological trauma of being first responders to mass shootings.

►We design trauma protocols to reduce the loss of life from even the most horrific gunshot wounds.

►We train civilians to carry and use tourniquets to #StopTheBleed, something that should be necessary on battlefields but not in American grade school classrooms.

►We try our best to conduct research to stop the epidemic of gun violence.

►We hold the hands of gunshot victims taking their final breaths.

►We cry, ourselves, as we tell parents that their child has been shot and that we did our best.

►We escort parents into our treatment rooms to take one last look at their dead child before they have been able to process the news.

►We see firsthand how a single moment ends a life and forever changes the lives of survivors, families, and entire communities.

NRA should help us reduce gun death toll

Our research efforts have been curtailed by NRA lobbying efforts in Congress. We ask that the NRA join forces with us to find solutions.

We invite the NRA to collaborate with us to find workable, effective strategies to diminish the death toll from suicide, homicide, domestic violence and unintentional shootings for the thousands of Americans who will one day find themselves on the wrong side of a barrel of a gun.

We are not anti-gun. We are anti-bullet hole. Let’s work together.

Join us, or move over! This is our lane. We as a society must do something about gun violence NOW!

Also, I live in a region where about 70% of the population owns guns. But the homicide and suicide rate is very, very low. Why? I’m not sure at this time but I along with the majority of our country are tired and scared of the gun-related violence.

The holiday of Thanksgiving reminds us that we ought to be thankful for the blessings and the people in our lives. But what do we do when it seems that everything is going haywire? Maybe somebody recently wronged you. An unexpected expense has thrown off your budget. That new role at your job isn’t as shiny as you thought it would be. Or maybe you’ve been trying to do the right things, live the right way, but situations STILL aren’t working out in your favor.

How do you cope? How do you resist the urge to give up? How do you continue to do good even when you’re not seeing any immediate benefits from “living the right way? And HOW IN THE WORLD can you be thankful for all of this? Sometimes we have to be thankful for what we have and enjoy the day and family and friends.

I had prepared two posts for tonight and wanted to hold off on the recent shootings until next week as we digest what the effect really is in our country and the future strategies. Now let’s discuss the effect of the election and in looking at the House Democrats, who have a lot to figure out on their signature issue.

Healthcare carried House Democrats to victory on Election Day. But what now?

Remember my past post reminding the Republicans the importance of healthcare in the midterm elections? We, it looks like it was an important factor in the outcomes of the “wave”. Dylan Scott spent some time looking at his prediction of what the new majority will bring to our health care system. In interviews this fall with half a dozen senior House Democratic aides, health care lobbyists, and progressive wonks, it became clear the party is only in the nascent stages of figuring out its next steps on health care.

The new House Democratic majority knows what it opposes. They want to stop any further efforts by Republicans or the Trump administration to roll back and undermine the Affordable Care Act or overhaul Medicaid and Medicare.

But Democrats are less certain about an affirmative health care agenda. Most Democrats campaigned on protecting preexisting conditions, but the ACA has already done that. Medicare-for-all is energizing the party’s left wing, but nobody expects a single-payer bill to start moving through the House. Drug prices offer the rare opportunity for bipartisan work with Senate Republicans and the Trump White House, but it is also a difficult problem with few easy policy solutions — certainly not any silver bullet that Democrats could pull out of the box and pass on day one, or even month one, of the next Congress.

Winning a House majority to ensure Obamacare’s safety is an important turning point after so many years in which health care hurt Democrats much more than it helped.

But the path forward for the party on their signature issue is surprisingly undefined.

The likely first item on the Democratic agenda: Obamacare stabilization

Democrats do have some ideas, of course. Democratic aides emphasized the various investigations they could launch into Trump’s health department, not only looking into any efforts by the White House to sabotage Obamacare but also focusing on more obscure issues like Medicare payment rates.

But wonky oversight inquiries probably aren’t the big-ticket item that new Democratic members and their voters are looking for, especially heading into the 2020 presidential election.

After campaigning in defense of Obamacare, warning about Republicans rolling back preexisting conditions protections and the Trump administration’s sabotage of the health care law, a bill to stabilize the Obamacare insurance markets would be the obvious first item for the new Democratic majority’s agenda.

Several sources pointed to a bill by Democratic Reps. Richard Neal (MA), Frank Pallone (NJ), and Bobby Scott (VA) — who have been serving as the top Democrats on leading health care-related committees — as the likely starting point. The plan is designed to build off Obamacare’s infrastructure to expand federal assistance while reversing the recent Republican efforts to undermine the law.

That bill would expand Obamacare’s premium subsidies, both by extending federal assistance to more people in lifting the current eligibility cutoff and by increasing the size of the tax credits people receive. It would also bolster the cost-sharing reduction subsidies that people with lower incomes receive to reduce their out-of-pocket costs while extending eligibility for those subsidies to people with higher incomes.

The Pallone-Neal-Scott bill would reverse the Trump administration’s recent regulations intended to funnel more people to insurance plans that are not required to meet all of Obamacare’s rules for preexisting conditions. It would also pump more money back into enrollment outreach, cut by the Trump administration, and establish a new program to compensate insurers for high-cost patients, with the hope of keeping premiums down.

Two things stick out about this bill: It would be the most robust expansion of Obamacare since the law first passed, and it is just narrow enough that, with a few sweeteners for Senate Republicans, it could conceivably have a chance to pass. Democrats are waiting to see how the GOP majority in the upper chamber reacts to losing the House.

“Undoing sabotage and bringing stabilization to the ACA markets, that’s something we should really be thinking about,” one House Democratic aide told me. “It depends on what kind of mood the Republicans are in. Maybe they’ll say that actually now that the tables are turned, we should probably sit down.”

Senate Republicans and Democrats did come very close to a narrow, bipartisan deal — it wasn’t even as robust as the Pallone-Neal-Scott bill — to stabilize Obamacare in 2017. It fell apart, ostensibly after a tiff over abortion-related provisions, but that near miss would be the reason for any optimism about a bipartisan deal on the divisive health care law.

Then again Senate Republicans might have no interest in an Obamacare compromise after gaining some seats. Democrats would still likely work on stabilization to send a message to voters on health care ahead of the 2020 campaign.

Shoring up Obamacare is a good start, but what next?

In the case, the Pallone-Neal-Scott bill might be a nice starting point — no Democrat really disagrees about whether they should help the law work better in the short term — but it still lacks any truly ambitious provisions. It is just about as narrowly tailored as an Obamacare stabilization bill offered by Democrats could be, a fact that aides and activists will privately concede.

Missing are any of the bolder policy proposals animating the left. Not even a hint of Medicare-for-all single-payer health care, which is or isn’t a surprise, depending on how you look at it.

Medicare-for-all is quickly becoming orthodoxy among many in the party’s progressive grassroots, and a single-payer bill proposed this Congress in the House (similar to the one offered by Bernie Sanders over in the Senate) has 123 sponsors.

But House Democratic leaders probably don’t want to take up such a potentially explosive issue too soon after finally clawing back a modicum of power in Trump’s Washington.

Still, the current stabilization bill doesn’t even include a Medicare or Medicaid buy-in, the rebranded public option that never made it into Obamacare but would allow Americans to voluntarily join one of the major government insurance programs. It is an idea that even the more moderate Democratic members tend to support, and polls have found three-fourths of Americans think a Medicare buy-in is a good idea.

The plain truth is House Democrats haven’t reached a consensus yet about what they want to do to cover more Americans. They agree Obamacare was an important first step, and they agree the status quo is unacceptable. But the exact mechanism for achieving those goals — single-payer, a robust public option, or simply a buffed-up version of Obamacare — is still very much up for debate.

“People will want to do something, but any further action is going to be a consensus-building process,” a senior House Democratic aide told me. “Democrats have lots of different ideas on how to continue working to reduce the uninsured.”

That is all well and good, but few issues are exciting the Democratic grassroots right now like Medicare-for-all. During the midterm campaigns, Democratic candidates and even grassroots leaders were happy to let those words mean whatever voters wanted them to mean. For some people, it meant single-payer; for others; it might mean a Medicare buy-in or something more limited.

The unreservedly progressive members who were just elected to Congress will only wait so long before they start pressing Democratic leaders to take more aggressive steps to pick up one of their top campaign issues. That pressure will only intensify as the 2020 presidential campaign heats up and Democrats debate what kind of platform they should run on as they seek to take back the White House.

For now, Democrats have tried to put off a difficult debate and focus on what unites them. But the debate is still coming.

The riddle of high drug prices still needs to be solved too

Even with Obamacare and preexisting conditions mobilizing Democratic voters this year, prescription drug prices remain a top concern for many Americans. That’s another area where Democrats know they want to act but don’t know yet exactly what they can or should do.

The issue could be an opening for serious dealmaking: Trump himself has attacked big pharma since his presidential campaign. His administration has actually launched some interesting initiatives to rein in drug costs — approving a record number of generic drugs, trying to even the playing field between America and foreign countries — that have some policy wonks intrigued, even if the impact is still to be determined.

Democrats have mostly stuck to slamming Trump for feigning to act on drug prices while cozying up to the drug industry. But it’s a top priority for both parties, and there could be some room for compromise. One progressive policy wonk thought a drug prices bill might actually be the first Democratic priority. It helps that drug prices are a populist issue that the new House majority might really be able to pass a bill on.

But first, Democrats have to figure out what exactly they are for — and what would actually make a difference.

The rallying cry for Democrats on drug prices has been letting Medicare directly negotiate prices with drug manufacturers, a proposal that Trump also embraced as a candidate, though he has since softened as president. The problem is the Congressional Budget Office doesn’t think Medicare negotiations would save any money unless the government is willing to deny seniors coverage for certain medications. But adding such a provision would surely invite attacks that Democrats are depriving people’s grandparents of the medications they need.

There are a lot of levers to pull to try to reduce drug prices: the patent protections that pharma companies receive for new drugs, the mandated discounts when the government buys drugs for Medicare and Medicaid, existing hurdles to getting generic drugs approved, the tax treatment of drug research and development. Lawmakers and the public view pharmacy benefits managers, the mysterious middlemen between health insurers and drugmakers, skeptically.

But none of those are silver bullets to lower prices, and they will certainly invite pushback from the politically potent pharmaceutical lobby, focused on the concerns about how much cracking down on drug companies to discourage them from developing new drugs. Democrats also don’t know yet what specific policies could win support from Senate Republicans or the Trump White House.

“How do you take this gargantuan Chinese menu of things and figure out how things fit together in a way that stem some of the abuses?” is how one Democratic aide summarized the dilemma.

It is a problem bedeviling Democrats on more than just drug prices. Health care was a winner on election night this year, and it has always been a priority for Democrats. Now they just need to figure out what to do.

Because tomorrow is Veterans Day I thought that I would include this article. After A Year Of Turmoil, New VA Secretary Says ‘Waters Are Calmer’

Quil Lawrence in his Twitter post reported on a wide-ranging interview with NPR, Secretary of Veterans Affairs Robert Wilkie said his department is on the mend after a tumultuous 2018.”I do think it is better because the turmoil of the first half of this year is behind us, the waters are calmer. We’re not where we need to be, but we’re heading in that direction,” he said.

Early in Donald Trump’s presidency, the VA was considered an island of stability in an unpredictable administration.

Secretary David Shulkin was a hold-over from the Obama administration, already familiar with the VA’s massive bureaucracy. Bipartisan reforms moved through Congress with relative speed, and Trump could point to a list of legislative accomplishments.

But the president fired Shulkin last March after weeks of intrigue during which VA political appointees plotted openly to oust him. Trump’s first nominee to replace Shulkin, Rear Adm. Ronny L. Jackson, sank under accusations of misconduct (which are still being investigated by the Pentagon).

Numerous high-ranking officials left the department, and records showed that friends of the president outside of government – who weren’t even veterans – had been lobbying Trump at Mar-a-Lago on how to run the VA.

After a stint as acting VA secretary, Robert Wilkie was confirmed by the Senate last July. Since then, Wilkie says he’s been “walking the post,” visiting as many VA facilities as he can. And he’s reached the same conclusion as many of his predecessors.

“I have been incredibly impressed by the caliber of VA employee I’ve encountered everywhere, from Alaska to Massachusetts to Florida,” Wilkie told NPR’s, Steve Inskeep.

“I have no quarrel with the quality of medical care our veterans receive. My biggest problem is actually getting them into the system so that they can receive that care, which means the problems are primarily administrative and bureaucratic,” said Wilkie, himself a veteran of the Navy and a current Air Force reservist, who counts generations of veterans in his family.

“I am the son of a Vietnam soldier. I know what happened when those men and women came home,” Wilkie said. “So that is incredibly important to me.”

Wilkie is navigating an important moment for the VA – while Congress has already passed major reforms, he’s the one who has to implement them. And plenty of political controversy hides in the details.

The VA Mission Act of 2018 was signed into law in June. It’s intended to consolidate about a half-dozen programs The VA uses to buy veterans private healthcare at a cost of billions of dollars, into one streamlined system.

Critics fear that leaning too much on private care will bleed the VA’s own medical centers, and lead to a drop in quality there – and amounts to a starve-the-beast strategy of privatization.

Wilkie says that won’t happen and is not President Trump’s goal, but he has yet to present a budget for expanded private care to the White House and to Congress.

“You’re not going to privatize this institution. I certainly have never talked about that with anyone in this administration,” Wilkie said.

Wilkie also maintains that he has had little contact with the group of outside advisers who meet with the president at Mar-a-Lago, including CEO of Marvel Comics Ike Perlmutter and Florida doctor Bruce Moscowitz. Records show they had extensive communication with the previous VA secretary, sometimes influencing policy decisions.

“I met with them when I was visiting the West Palm Beach VA – my first week as acting (secretary), and have not had any meetings with them ever since that day,” Wilkie said. “I’ll be clear. I make the decisions here at the department, in support of the vision of the president.”

Despite rumors that Wilkie would clear out many of the Trump political appointees who clashed with former secretary Shulkin, he said he didn’t expect more staffing changes.

The one notable departure is Peter O’Rourke, who was acting secretary for two months while Wilkie went through the confirmation process. O’Rourke clashed repeatedly with Congress and the VA’s inspector general. Wilkie himself cited a Wall Street Journal reports that O’Rourke is poised to go and said he’s “on leave.”

“I think there will be an announcement soon about a move to another department in the federal government – I know that he’s looking for something new,” said Wilkie, “He’s on leave.”

Another major new plan that Wilkie must implement is a $10 billion, 10-year plan to make the VA’s medical records compatible with the Pentagon’s.

He once again mentioned his father’s experience as a wounded combat vet.

“He had an 800-page record, and it was the only copy, that he had to carry with him for the rest of his life. He passed away last year,” said Wilkie.

“One of the first decisions I made as the acting secretary was to begin the process of creating a complete electronic healthcare record that begins when that young American enters the military entrance processing station to the time that that soldier, sailor, airman, Marine walks into the VA.”

But that process has actually been underway for a decade – with little to show and about a billion dollars already spent on the effort. The non-partisan Government Accountability Office says it’s in part because neither the Pentagon nor the VA was put in charge of the effort — which is still the case. Wilkie says he has signed an agreement with the Pentagon to jointly run it with clear lines of authority.

“I think we’ll have more announcements later in the year when it comes to one belly-button to push for that office,” he said.

As for staff shortages, another perennial complaint at the VA, Wilkie acknowledged there are 35- to 40,000 vacancies at the agency.

“We suffer from the same shortages that the private sector and other public health services suffer from, particularly in the area of mental health,” he said.

New legislation passed this year gives Wilkie the authority to offer higher pay to medical professionals.

“I’m using it to attract as many people as we can into the system,” said Wilkie

But Wilkie also added that he was shocked, upon taking the post, that it’s not clear how many additional people are needed – because it’s not even clear how many people are working at VA.

“I had two briefings on the same day and two different numbers as to how many people this agency employs.”

Wilkie says he’s in the process of finding out the answer to that question, and many others, as he starts his second 100 days in office.

And to end this post I must include this note. I was raised in the Bronx, New York and are truly embarrassed to acknowledge that the new Congresswoman Cortes-Ortes who was elected, and not sure how when you look at her qualifications and knowledge. But more, she is a socialist and expects everything to be given to all and the government will foot the bill and now listen to this.

Ashley May, a reporter for the USA TODAY noted that the upset primary win in New York by Alexandria Ocasio-Cortez is a huge moment for the Democratic Party because it shows the left-wing base is energized heading into the midterms, according to AP National Politics Reporter Steve Peoples. (June 27) AP

Alexandria Ocasio-Cortez, the youngest woman elected to Congress in the midterm elections, is struggling to pay rent, according to a recent interview.

Ocasio-Cortez, 29, told The New York Times she’s not sure how she will be able to afford an apartment in Washington, D.C., without a salary for three months in an interview published online Wednesday.

She told the Times she has some savings from her job earlier this year as a bartender at a Union Square restaurant, and she’s hoping that will hold her over. Living without a paycheck is something she said her and her partner tried to plan for, but it’s a hardship that’s still “very real.”

“We’re kind of just dealing with the logistics of it day by day, but I’ve really been just kind of squirreling away and then hoping that gets me to January,” she told the Times.

Ocasio-Cortez is a New York activist and Democrat who will represent the 14th Congressional district, which covers the Bronx and Queens.

Thursday, she pointed to her lack of income as a reason why some people are not able to work in politics.

“There are many little ways in which our electoral system isn’t even designed (nor prepared) for working-class people to lead,” she said.

She said she hopes she can change that.

Yes, and now if she plays her cards right she has a job, paying better than any job that she is really qualified for life.

Buck it up Ocasio-Cortez, live outside of DC and take public transportation like most people do!

How did you fund your campaign? I don’t want to hear your sob story and yes I am ashamed that the borough of the Bronx has you for their representative. What a joke! You said that when you got to DC you were going to sign a whole lot of bills and laws to make things better. Do you even know anything about the process and have you ever taken a Civics course. You are in for some big surprises… called reality!

On a better note-Happy Veterans Day and thank you all who have served in our military and those who are still out there helping to make this world a better place to live and protecting our freedoms.

Now that the Mid Term elections are upon us I can honestly state that I am somewhat ambivalent regarding the outcome. I’m pretty sure that the Democrats are going to claim the majority in the House and maybe the Republicans will hold onto the Senate. But to what end. The fighting will go on and probably nothing will get done. The Republicans have no one to blame but themselves for losing the House majority. Where was their leadership and don’t point fingers at the President? His leadership roles could be questioned but the big issue is that leader Ryan, although I like him was no leader as well as so many Republican Congressmen and women deciding to retire at such an important time and therefore not supporting their President.

The Democrats have disgusted me with their horrible behavior and attacks and playing the blame game Their leadership just sickens me during these last 2 years and them look who we have to run for the Presidency, again members who truly have made things worse, not better and not even trying to negotiate, be civil and spouting lies and attacks. As I said both parties have sunken to new lows in their behavior. I wish that we did have a significant Third Party for whom I would vote for. Again it holds your nose and vote.

Our friend, Joyce Frieden the News Editor of MedPage reported that Healthcare is expected to be a major issue in the November election — not just in Congress but also in the states. With that in mind, MedPage Today is profiling several candidates for statewide office who are focusing on healthcare issues. In our third and final profile, we speak with Jon Santiago, MD (D), an emergency room physician who is running for the Massachusetts House of Representatives.

Jon Santiago, MD, saw it firsthand every day. “I work in an ER at Boston Medical Center and it’s a great job,” Santiago said in an interview with MedPage Today. “It’s a job I love in a hospital I’ve wanted to work at since I was a kid.”

Naturally, Santiago, a fourth-year emergency medicine resident, tackles difficult problems as an emergency physician — including gunshot wounds, strokes, and heart attacks. “I live for those exciting moments, but you begin to realize that working in an ER, you’re taking care of a lot of social issues — poverty, racism, sexism, and lack of economic opportunity or housing — that ultimately manifest in some kind of medical condition, and that’s when we treat them.”

“We’ll literally or figuratively put a Band-Aid on them … but it’s not until we solve the social determinants of health that we begin to [really] solve their problem,” he continued. “That’s why I decided to run for office.”

Opioid ‘Ground Zero’

As a public hospital, Boston Medical Center is “ground zero” for the opioid epidemic, both in the city and the state, Santiago said. He cited the example of Long Island, an island near Boston that houses a number of homeless shelters and recovery services. “There was a bridge to an island near Boston that overnight had to be shut down because it was dangerous, so in a matter of days, we had to move about 400 people into the [South End] neighborhood, many of whom were homeless and had substance use disorder. It really changed the community.”

In addition, for those people that had to be moved, “their continuity of care stopped, and as a result, people died … My run for office is really for these patients I take care of who need the help, but also for significant quality-of-life issues in the community.”

Santiago noted that with its many world-class healthcare facilities, Boston is considered the “healthcare capital of the state, if not the country and the world.” But the state also has its own healthcare challenges — Massachusetts’ Medicaid program, known as MassHealth, takes up 40% of the state budget. “And Massachusetts likes to pride itself that we were the first to pass health care reform, providing universal coverage, but that doesn’t mean healthcare is affordable or accessible.”

For example, “MassHealth doesn’t cover everything; there is always talk of cutting certain services,” said Santiago. “Just this past year, the governor threatened to knock out about 140,000 people from MassHealth to save money.”

Technically, the coverage rate in the state is 97%, but “the question is, if you look at what people pay for the administration of private healthcare, the costs are significantly more than a public provider would have,” he said, noting that Medicare’s administrative cost is about 10%. “Other developed countries are able to provide more cost-effective healthcare with … better outcomes.”

Santiago supports single-payer universal health care coverage for all state residents through a “Medicare for all” system. The first step toward that goal, he said, would be to study single-payer and compare the current system to what single-payer would look like “and if it would save money, I would pursue that because what we have is not really sustainable.”

An Unlikely Winner

Santiago was an unlikely winner in the Democratic primary race in his district. “I beat a 36-year incumbent who was the majority leader, the fourth highest-ranking person in the state,” he said. “What people were looking for [was] people to provide political leadership on issues that matter, and when it comes to the opioid epidemic, people were looking for solutions.” Santiago attributes his victory to a very grassroots strategy. “I personally knocked on 8,000 doors; we knocked on every door in the district. If you talk to people and listen to them, you’re better able to serve their needs.”

“The person representing this district — the center of the epidemic — should be a leader on this issue,” he continued. “Massachusetts Avenue they call the ‘Methadone Mile’ here; I live close to that. The Boston Medical Center emergency department is located there, and as an emergency department provider, it gives me initial insight into what is going on, on the ground.”

He gave an example of how, 3 years ago, his experience helped him change the law. “In my first year as a doctor, with the prescription drug monitoring program (PDMP), if someone comes in with back pain, you check to see whether they have previously been given an opioid prescription — if they have, it’s a red flag. I tried to look [at the PDMP] during my first year as a doctor, and I couldn’t access the website. I turned to my attending and he said, ‘Only attendings can.'”

But since the residents do much of the work at the hospital, “I said, ‘This doesn’t make sense,'” said Santiago. “I got the doctors together and we started a petition to provide access [to the PDMP] to the residents who do all the work. I got the petition started, met with the Boston Globe, and they covered it; we met with the governor’s staff and they changed the law overnight. Within a week or so, residents across the state were able to access the PDMP.”

Post-Election Plans

If Santiago wins the election, “my plan is to continue working as an ER doctor because I think one job really informs the other,” he said. “One job really keeps you close to the community and the issues neighbors face day in and day out, and working as a state representative addresses those issues in the policy arena.” A total of 14 8-hour shifts per month are considered full-time; Santiago said he planned to work one to two shifts a week during the legislative session, “and I’d be the only physician [legislator] in the capital as well.”

Public service is nothing new to Santiago, who served as a Peace Corps volunteer in the Dominican Republic and is currently a captain in the Army Reserve. “I graduated from college and wanted to join the military, but I was not enthusiastic about the Iraq War,” he explained. “I wanted to serve my country, so I joined the Peace Corps … I told myself that if I became a doctor I would join the Army Reserve so I could serve in that capacity.” The reserves are pretty flexible since they only require one weekend a month and 2 weeks a year, and if you do deploy it’s only for 3 months, he added. “But they’re very flexible with you if you’re a doctor.”

In Trump midterms, one GOP congressman bets re-election on healthcare

Reporter Susannah Luthi noted that Rep. Peter Roskam (R-Ill.), in the final sprint for his congressional life, wants to talk about Medicare red tape. The message is a big deal in his hospital-dominated district that headquarters the state’s largest system, Advocate Health Care. His health subcommittee chairmanship for the powerful House Ways and Means Committee positions him to push measures that resonate when hospitals attribute 25% of their spending, or about $200 billion per year, to paperwork.

But while policy specifics may matter for his committee work and for the business of healthcare, analysts are skeptical they can prevail over the “Trump effect”—widespread rejection of the president by moderate suburban Republicans, which makes elections in places like the Illinois 6th District a national more than a local referendum.

Roskam now lags in the polls behind his Democratic challenger Sean Casten, a clean energy entrepreneur who has harnessed local opposition to President Donald Trump to pull ahead of a six-term congressman of a district that was designed as a GOP stronghold.

Questioning the 80/20 rule for healthcare

The 80/20 rule in health care underlies much of the common thinking about population health. Many value-based strategies about health care costs or utilization use this rule to describe the distribution of health care spending. Is the 80/20 rule accurate today? We analyzed recent data to find out.

He’s also struggling to make another national healthcare message local.

The term “pre-existing conditions” is headlining the cycle. The tagline has become particularly effective in light of the GOP state attorneys general lawsuit to strike down the Affordable Care Act. The Trump administration sided with the lawsuit, specifically asking the courts to overturn the provisions around community rating and other cover requirements that prohibit insurers from charging more for people with expensive, pre-existing conditions.

Roskam voted with most of his party for the GOP effort to repeal and replace the ACA, and Casten has been pounding him for it.

But on a rainy Friday in early October, as he toggled between campaign events and representational duties that involved a deep dive into CMS pay rules for disabled adults in the community, Roskam stuck with his policy line. He said this still matters in what he described as his “solution-oriented” district.

“My observation is that if the ACA were doing what it’s purported to do, the district wouldn’t be restless and they’d be quick to turn the page,” Roskam said. “But they are restless and there is a sense of vulnerability that’s out there and it’s largely financial.”

Then he pivoted to what he has been working on as a congressman: the Medicare Red Tape Relief project that culminated in a report late this summer, which he believes is more relevant for bringing costs down.

“The country feels stuck in a debate [over Obamacare] and it’s ready to get out of the ditch of the debate,” Roskam said. “It’s well litigated where both sides are on the ACA. And these continuous declarations—most people don’t find a level of connection. Which is why the red-tape relief effort resonates. ‘Yes, I get that, my doctor is looking at a screen half the time he’s with me. That’s not the way it used to be.'”

But that’s not the focus in this race. After millions of dollars in advertising from both sides, Roskam is trailing by five points in the latest FiveThirtyEight poll. The nonpartisan Cook Political Report rates the race as “lean Democratic” as Casten pummels Roskam’s record of voting 94% of the time for Trump’s agenda.

The flip is emblematic of what’s happening in moderate suburbs that voted for Hillary Clinton in 2016, said David Wasserman, House editor of Cook Political Report. That’s when Roskam cruised to a double-digit victory even though Clinton beat Trump by seven points in his district.

Casten, whose core issue is climate change, wasn’t necessarily the strongest Democratic candidate for the district, Wasserman added. He wasn’t the favorite in his primary and even Democratic strategists complain about his bombastic style. But none of this may matter.

“Roskam has failed to make the race a referendum on Casten, and it’s become about Trump and Roskam,” Wasserman said.

In Roskam’s case, there are also state-based headwinds: a deeply unpopular GOP governor who is motivating Democratic voters in the state, and a GOP president who is unpopular in a prosperous GOP district.

“If Peter wins, it’s because people are willing to look at him as someone who is independent of Trump and has been a good representative of the district,” a longtime GOP Illinois strategist said.

At a Casten sit-down with local members of the Illinois Alliance for Retired Americans as the group endorsed him, the dissatisfaction with healthcare played out in condemnations of Roskam’s 2017 vote to repeal the ACA. They talked about denials of care by insurers through pre-authorizations they didn’t understand, their fears about the future of coverage for pre-existing conditions, and Medicare’s solvency.

Kim Johnson, a retired state worker who is taking care of two of her grandchildren, said that one granddaughter was born with a heart condition and blasted Roskam for his 2017 vote saying that if he “had his way, she’ll have no insurance.”

But the status quo is also not enough, Johnson added, noting that she wants to see “universal healthcare.”

“I just want to see something,” she said. “I want to see something improve. We are a much better country than what our benefits are.”

Casten reiterated his support for the ACA and said he wants to look at a public option through an expansion of Medicare or Medicaid or both.

But he has steered clear of the more progressive Democratic positions. He criticized the Medicare for All proposal of Sen. Bernie Sanders (I-Vt.) as “irresponsible” and said it made him nervous. At the table of retirees, Casten also defended the for-profit nature of the U.S. system, which he said drives the right incentives for efficiency.

He has also drawn a hard line about what he thinks about Republicans, and about working with them. “On almost everything we are arguing about, there are no areas for compromise,” specifically on the confirmation of Justice Brett Kavanaugh to the Supreme Court, climate change and voting rights, Casten told a group of nursing home residents in one event.

Roskam recently ranked as the 25th most bipartisan House member out of 435 lawmakers, is banking on his district rejecting that approach. Issues like Medicare fraud and Medicare solvency matter, he said, but big policy pushes need buy-in from both Democrats and Republicans and work needs to be incremental.

Roskam has blasted Casten’s campaign speech—and his active Twitter feed—as Trump-like. But in the last stretch of the race, the rhetoric has intensified, thanks to the millions of dollars raised for ads that are barraging the district and even its surrounding counties. Campaign signs blanket lawns and the roads connecting this leafy, prosperous district.

James, a nursing home resident who had attended Casten’s event there and who declined to give his last name, said that what he will be watching for this election is what it will say about voters’ views of Trump.

“Are people catching on with what Trump is doing?” James said. “Everybody’s got a right to vote—that’s a good thing and a bad thing. Hopefully, people will catch on to what’s going on.”

Healthcare and the midterms: I’ve got you covered

Healthcare is top of mind for many 2018 midterm voters. As they select state and federal representatives, many ballots also include measures for Medicaid expansion, provider pay and other key healthcare issues. Federal policy on the future of the Affordable Care Act, drug prices and immigration reform will also affect the healthcare industry. I thought that I would use this article to summarize the MidTerm issues.

Modern Healthcare has been tracking how policy changes and discussion could affect the midterm elections. A change in House or Senate party control or governors’ races can tilt the scale on many hotly contested healthcare issues. Here we’ve rounded up our coverage on the upcoming midterm election.

Midterm elections 2018 at a glance

– 2018 elections: The future of healthcare could be purple: In the lead-up to the midterms, Democrats appear poised for gains in Republican-controlled legislatures and governor’s mansions, which could push the states to make the healthcare compromises that Washington can’t.

– In Trump midterms, one GOP congressman bets re-election on healthcare: In an intense congressional race in the Chicago suburbs, hospital ally Rep. Peter Roskam (R-Ill.) is running on an anti-regulatory healthcare message. But in a referendum election about Trump, how will that play?

– The 115th Congress on the State of Healthcare: Modern Healthcare’s 115th Congress on the State of Healthcare is a featured collection of commentaries from lawmakers and healthcare organization leaders. Included in this collection of Congressional commentaries are six editorials from U.S. Senators and eight House Representatives across both party lines.

– Data Points: Healthcare tops the polls as midterms loom: The all-important 2018 midterm elections are less than two months away. As special elections and primaries, this summer has proven, healthcare continues to be a hot-button issue.

– Editorial: Healthcare PACs voting for incumbent protection: Many Democratic congressional hopefuls are making healthcare their top talking point for the upcoming midterm elections, which is not surprising given the low unemployment rate. The early donations from political action groups lean toward the incumbents.

– House Speaker Ryan to retire with a mixed legacy on health policy: House Speaker Paul Ryan’s upcoming retirement from Congress after leading the GOP’s charge to repeal the Affordable Care Act leaves his party in a challenging place on health care messaging ahead of the 2018 midterm elections.

Status of Medicaid expansion states and work requirements

– Bullish post-election Medicaid expansion outlook may not match end result: Although a new report predicts 2.7 million people in nine states could soon become eligible for Medicaid, expansion could look very different state by state.

– Medicaid expansion on the prairie: Nebraska’s ballot initiative heads to the polls: Four years into Obamacare, the majority of Nebraska voters support Medicaid expansion, a key measure on their midterm ballot. But even pro-expansion hospitals are taking a cautious view of how much it will impact the rural bottom line.

– Verma touts Medicaid work requirement successes, despite coverage loss: CMS Administrator Seema Verma insisted that Medicaid work requirements are working as intended to move people out of poverty, despite criticism that they’re doing more harm than good.

– Medicaid blues: Hospitals, insurers wage a political battle over managed-care dollars: Medicaid, the 50-year-old federal-state health coverage plan for the poor, has devolved into a political inter-industry feud in the impoverished Mississippi Delta. What does the fight foretell about the Medicaid industry and how it treats the nation’s poorest?

– Could deep-red Miss. expand Medicaid? 2019 will tell: A Mississippi state senator has introduced a bill to expand Medicaid every year since Obamacare went into effect, but so far it’s been off the table. The 2019 governor’s race could change the picture.

– Close governor races could decide future of Medicaid: Advocates say the single biggest factor in expanding Medicaid in balky states has been the election of a governor who supports it.

– Editorial: Want people off Medicaid? Give them more access to it: New research found those who gained coverage through Michigan’s Medicaid expansion faced fewer debt problems, fewer evictions, and bankruptcies, and saw their credit scores rise just years after enrolling for coverage.

– Wisconsin can impose Medicaid work requirements, time limits, but not drug testing: The CMS on Wednesday gave Wisconsin permission to impose work requirements on beneficiaries. It’s the first state to receive a green light for the policy without expanding Medicaid. The agency rejected the state’s mandatory drug testing proposal.

– Tennessee joins push for Medicaid work requirements: Tennessee is the fourth state this month to introduce a work requirement proposal for its Medicaid enrollees. Officials there believe it has a better chance of CMS approval than other non-expansion states due to its coverage policies for adults.

– House Democrats press HHS for Medicaid work requirement records: Two top Democrats on the House Oversight Committee want to subpoena the Trump administration’s documents around its Medicaid work requirement policy. HHS officials haven’t responded to their previous requests for information.

– Senate Republicans in talks with Verma to expedite states’ 1332 waivers: The Senate’s two top GOP proponents for individual market exchange stabilization measures are in talks with CMS Administrator Seema Verma about making 1332 state innovation waivers easier to obtain.

Affordable Care Act:

– Editorial: The midterm elections will decide the fate of the ACA: If the GOP maintains control of the entire government, the nation’s health insurance marketplace would look a lot like the one that existed before passage of the Affordable Care Act.

– Judge skeptical of ACA’s standing without effective individual mandate penalty: In a U.S. district court Wednesday, a federal judge had hard questions for Democratic state attorneys general who argued that the ACA can stand even with a zeroed-out tax penalty.

– ACA court case causing jitters in D.C. and beyond: A lawsuit aiming to overturn the Affordable Care Act goes before a conservative Texas judge Sept. 5. The health insurance industry and GOP lawmakers are bracing for the potential fallout.

– Uncertainty could spook insurance markets as DOJ decides not to defend ACA: The Department of Justice has asked a federal court to invalidate three key Obamacare coverage mandates, siding with a red state lawsuit against the Affordable Care Act and spurring new uncertainty for the 2019 individual market.

– Republicans weigh electoral calculus on reviving ACA repeal push: Both Republican and Democratic political observers see a narrow possibility for yet another Obamacare repeal drive this year, given intense pressure from conservatives and the urgent GOP need to fire up right-wing voters to maintain their control of Congress in this fall’s elections.

Pre-existing conditions:

– Pre-existing conditions drive state attorney general campaigns: Democratic candidates in state attorney general races have leveraged their party’s national campaign strategy around coverage of pre-existing conditions. They’re trying to beat Republican incumbents who are suing to end Obamacare.

– Will Republicans keep their new promises on pre-existing condition protections?: Despite congressional GOP candidates’ promises, health policy analysts doubt whether victorious Republicans would move to replace those ACA protections with equally strong measures to cover people with health conditions as part of repeal legislation.

– Tight Iowa congressional races key on pre-existing condition protections: The battle over pre-existing condition protections has become particularly heated in two toss-up House races in Iowa, even as unregulated Farm Bureau health plans that can use medical underwriting will go on sale Nov. 1.

– GOP senators propose new protections for challenged ACA provisions: As the country heads toward midterm elections and red states look to overturn Obamacare in the courts, Republican senators have introduced a bill to preserve some of the law’s most popular provisions.

Medicare for all:

– Verma argues ‘Medicare for all’ would cause physician shortage: In a speech to insurers, CMS Administrator Seema Verma claimed patients would struggle to find a doctor if the U.S. implements “Medicare for all.”

– ‘Medicare for all’ proves to be a tricky issue for Democrats: Progressive Democrats want to wrestle “Medicare for all” into their party’s platform. But Democratic strategists and the results of recent primaries say the country isn’t ready for it yet.

Drug prices in America

– Editorial: Drug price controls? A good idea, but don’t bet on it: Once the heat of the campaign dissipates, a majority in both parties will remain susceptible to their main argument that high prices are necessary to promote innovation.

– The fate of Trump’s Part B drug cost plan may depend on the Dems winning House: Trump’s Medicare Part B drug cost plan could move forward, particularly if Democrats win control of the House.

– New CMS pay model targets soaring drug prices: The Trump administration’s first mandatory CMS pay model is projected to save taxpayers and patients $17.2 billion over five years by shifting Medicare Part B drugs to price levels more closely aligned with what other countries pay.

– 340B showdown: Big pharma, hospitals squaring off in lobbying fight: Hospitals have adopted a take-no-prisoners approach in the fight with Big Pharma over the 340B drug discount program. Can this strategy hold as Congress, oversight agencies, the courts and the Trump administration ratchet up scrutiny of the program?

Midterms 2018 ballot measures

– Editorial: Medicaid expansion, dialysis, staffing ratios get grassroots push: Grassroots activism is behind both good and bad trends in policy. Consumer coalitions are behind Medicaid expansion ballot measures in several states, while other coalitions are pinpointing dialysis policy and staffing ratios.

Nurse-to-patient staffing ratios in Massachusetts

– Mandated nurse-to-patient ratios spark high costs, few savings: Massachusetts voters in November will determine whether mandated staffing ratios for registered nurses will go into effect Jan. 1. Implementing the ratios could cost providers $676 million to $949 million per year.

– Data Points: A state-by-state look at nurse-to-patient staffing ratios: As nurse-to-patient ratios are debated on both coasts, projections show a few states may not be able to meet future demand for registered nurses.

Dialysis ballot measure in California:

– Dialysis Cos. dole out more than $100M to beat Calif. ballot measure: With just a few weeks to go until November’s elections, the dialysis industry has raised more than $105 million to defeat a ballot measure that would cap their profits at 15% of direct patient-care costs.

– Calif. governor vetoes dialysis reimbursement cap: Dialysis giants DaVita and Fresenius won a major victory in California as Democratic Gov. Jerry Brown vetoed a bill that would have slashed and capped their reimbursement rates.

Impact of immigration on healthcare

– Children’s hospitals bear the largest brunt of Trump immigration crackdown: Children’s hospitals could see their revenue dip if increased anti-immigration sentiment from the Trump administration causes an exodus from Medicaid. Chronically ill children on Medicaid primarily go to these facilities for their hospital stays.

– Clinics catering to immigrants take a hit from White House policy: Healthcare providers who care for refugees are faced with the financial strain of having fewer new patients as a result of the Trump administration’s limits on immigration.

– Healthcare groups blast proposed rule penalizing immigrants for using public benefits: The Department of Homeland Security published a proposed rule that would allow immigration officials to consider legal immigrants’ use of public health insurance, nutrition and other programs as a strongly negative factor when applying for legal permanent residency.

– Immigrant detention crisis could yield a profit for some providers and payers: The influx of immigrant children under HHS’ care translates into big contracts for providers charged with the children’s medical treatment.

– Trump’s immigrant healthcare rule could hurt low-income populations: The Trump administration reportedly is nearing completion of a new immigration rule that health care providers and plans fear will harm public health and their ability to serve millions of low-income children and families.

– What do U.S. immigration policies mean for the healthcare workforce?:

There’s been a drop in the number of foreign-born medical graduates applying for residencies in the U.S. at the same time that the country struggles with physician staffing shortages. Industry stakeholders worry the decline comes from recent efforts to stem immigration.

So, everybody hold your noses, do your research and VOTE! We’ll see what happens Tuesday!